Every finding on record at Harrison Pointe Healthcare and Rehabilitation

Based on observation, interview, and record review, the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not meeting the manufacturer requirements. Findings included: On 3/1/26 at 8:32 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated the dish machine was a low temperature machine. The dish machine had a label which revealed that the wash temperature should reach 120 degrees Fahrenheit minimum and the rinse temperature should reach 120 degrees Fahrenheit minimum. On 3/4/26 at 9:00 AM, the following observations were made of the dish machine: [Note: All temperatures (temps) were in degrees Fahrenheit.]a. At 9:00 AM, the wash temp was 110 and the rinse temp was 120. There were plates, bases, and trays observed to be washed in the dish machine cycle. The dishes were observed to be put away with the clean dishes at 9:13 AM, by the Dietary Manager (DM). b. At 9:14 AM, the wash temp was 105 and the rinse temp was 117. There were trays, plates, and bases observed to be washed in the dish machine cycle. At 9:20 AM, the DM put away the trays with clean trays. c. At 9:15 AM, the wash temp was 105 and the rinse temp was 119. There were plates, bases, and trays observed to be washed in the dish machine. At 9:21 AM, all plates, bases, and trays were put away with the clean dishes. d. At 9:21 AM, the wash temp was between 105 and 110. The rinse temperature was at 120. There were trays and domes observed to be washed in the dish machine. The trays and domes were put away with the clean dishes. e. At 9:28 AM, an observation of the dish machine temperatures were observed with [NAME] 1. [NAME] 1 verified the washing temperature was 110 and the rinse was 120. [NAME] 1 checked the sanitizer and it was 100 parts per million. [NAME] 1 stated the dish machine needed to run a few times for it to reach 120 for the washing cycle. f. At 9:30 AM, the wash temp was observed to be 118 and the rinse was between 122 and 124. [NAME] 1 verified the temps. [NAME] 1 stated to the DM the washing temperature was not high enough. g. At 9:34 AM, an observation was made with the DM using the digital thermometer in the dish machine water. The digital thermometer was 114.6 for the wash and rinse was 123. The dish machine thermometer had the same temperature reading. The dish machine temperature log was reviewed and the DM signed that the washing temperature was 120 and rinse was 120 on 3/4/26, for breakfast, despite the above observations. On 3/4/26 at 9:37 AM, an interview was conducted with the DM. The DM stated he checked the dish machine about 8:00 AM, and the temperatures were at 120 for the wash and the rinse. The DM stated sometimes the dish machine thermometer did not work so he used the digital thermometer which had the same reading. The DM stated he was going to get the Maintenance Director to look at the dish machine. On 3/4/26 at approximately 10:30 AM, an interview was conducted with the Director of Nursing and the Administrator. The Administrator stated the facility had a contractor working on the washing machines which was probably why the dish machine temperatures were lower.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 3 out of 29 sampled residents, a resident with a surgical wound did not have Enhanced Barrier Precautions (EBP) posted or in place; appropriate hand hygiene and glove changes were not performed between dirty and clean tasks or resident contact; and during a dressing change a clean field was not maintained and bandages were contaminated. Resident identifiers: 9, 32, and 59.Findings included: 1. Resident 59 was admitted to the facility on [DATE] with diagnoses which included displaced trimalleolar fracture of right lower leg and syncope and collapse. Review of resident 59's medical record was completed on 3/1/26 through 3/4/26. On 2/19/26, a physician's order documented, ENHANCED BARRIER PRECAUTIONS: PPE [person protection equipment] required for high resident contact care activities. Indication: Right ankle external fixator. every shift for Surgical wound. On 3/1/26 at 3:03 PM, an observation of resident 59's room was conducted regarding the implementation of EBP. The observation revealed that there was no EBP notification or signage posted outside of the room to alert staff of required precautions. Furthermore, there was no PPE, such as gowns or gloves, available for use either inside or immediately outside of the resident's room. On 3/3/26 at 8:33 AM, during wound care treatment for resident 59, the following was observed: a. At 8:33 AM, Registered Nurse (RN) 3 was observed entering resident 59's room. She discussed the necessity of wound care with the resident and asked if she could perform the treatment. b. At 8:37 AM, RN 3 was observed placing a chuck (disposable underpad) directly on the floor to serve as the surface for wound care supplies. c. At 8:39 AM, RN 3 was observed donning gloves and removing the soiled bandage from the left (L) calf. The procedure was completed without donning any required EBP or PPE beyond gloves. d. At 8:40 AM, RN 3 was observed to clean the site on L calf and apply a clean bandage using the same gloves used to remove the soiled dressing. It should be noted that no hand hygiene was performed during the transition from dirty to clean tasks. e. At 8:42 AM, RN 3 was observed unwrapping an ACE bandage from the right (R) leg while still wearing the contaminated gloves from the treatment on the L calf. f. At 8:45 AM, RN 3 was observed removing her gloves and donned a fresh pair. RN 3 removed the gauze wrapping and ACE bandage over a R dorsal foot blister. g. At 8:47 AM, RN 3 was observed obtaining clean gauze, sprayed it with wound cleaner, and patted the blister on R foot. RN 3 continued to spray clean gauze and cleaned pin sites on the lower half of the R ankle external fixation surgical device. h. At 8:48 AM, RN 3 was observed removing her gloves and proceeded to open gauze packets, remove the gauze, and cut the gauze pad. This was noted to be performed with her bare hands. i. At 8:51 AM, RN 3 was observed donning a new pair of gloves and proceeded to remove the remaining gauze on the upper half of the R ankle external fixation surgical device. j. At 8:54 AM, RN 3 was observed cleaning the pins of the upper half of the R ankle external fixation surgical device with wound spray and gauze. k. At 8:55 AM, The Maintenance Director was observed entering the room and stepping over the wound supply field. l. At 8:55 AM, an observation was made of RN 3 at which time she sprayed a piece of the cut gauze with wound spray then wrapped it around each one of the pins. It should be noted that no hand hygiene was performed during the transition from dirty to clean tasks. m. At 8:57 AM, an observation was made of RN 3 applying the clean gauze wrap around the lower R leg. n. At 9:00 AM, RN 3 was observed reapplying the ACE wrap that had been previously removed. RN 3 stated to resident 59 that the ACE bandage was changed every other day. o. At 9:03 AM, RN 3 was observed gathering used supplies and tossed them into the trash can inside the resident's room and left the room. It should be noted, the contaminated supplies were left in the room upon her exit. On 3/4/26 at 8:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that when a resident was on EBP, she clarified the specific precautions with the nurse. CNA 1 stated that she would don PPE when providing direct care or when she expected to be in close proximity to the resident. Furthermore, CNA 1 stated that according to her understanding of facility practice, it was not necessary to don PPE when entering the resident's room for non-care tasks, such as delivering meal trays. On 3/3/26 at 9:15 AM, an interview was conducted with RN 3. RN 3 stated that she recently began working at the facility and was currently still in training, noting that she was not yet fully familiar with the facility's specific EBP policies. During the interview, RN 3 identified that residents exhibiting coughs, or those with bodily fluids or wounds, should have orders in place for EBP. RN 3 further stated that residents admitted from the hospital with indwelling devices would also require an order for precautions and EBP. Regarding her clinical practice, RN 3 stated that she dons PPE upon entering a resident's room for pretty much any care involving direct contact. On 3/4/26 at 8:42 AM, a follow-up interview was conducted with RN 3. RN 3 initially stated that an external fixation device was not an open wound. RN 3 explained this assessment was based on her extensive experience in wound care, which led her to view the sites as closed. However, upon further discussion, RN 3 corrected her statement, acknowledging that because the pins create a direct opening to the body, the site was technically an open wound. On 3/4/26 at 9:17 AM, an interview was conducted with RN 2. RN 2 stated that residents with indwelling medical devices (tubing entering the body) or open wounds require EBP. RN 2 indicated that PPE should be donned prior to entering the room, specifically when working near the site of entry or during close contact with the resident. RN 2 stated that an external fixation device was considered a closed device. RN 2 confirmed that PPE must be worn when performing bandage changes for such devices to maintain proper infection control. On 3/4/26 at 10:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents requiring EBP include those with feeding tubes, Multi-Drug Resistant Organisms , chronic wounds, intravenous treatment, catheters, or any indwelling devices. The DON stated these requirements were documented in the physician's orders and the resident's care plan. The DON stated that staff should wear PPE when providing close proximal care or performing any direct resident care. The DON stated she would classify an external fixation device as a surgical wound but noted she was consulting a reference for further clarification. During the interview, the DON confirmed that resident 59, did in fact have an order in place for EBP. The DON stated that facility policy requires clean technique and that gloves must be changed, with hand hygiene performed, between dirty and clean procedures during the same treatment. 2. On 3/3/26 at 6:30 AM, during morning medication pass the following was observed: a. At 6:31 AM, Licensed Practical Nurse (LPN) 1 was observed to touch her computer keyboard, the computer mouse, the top of the medication cart, and the medication cart keys. LPN 1 was then observed to begin removing medication packs for resident 9 from the medication cart and place them into a medication cup. b. At 6:33 AM, LPN 1 was observed to hand the medication cup to resident 9 and resident 9 took his medication. It should be noted that LPN 1 had not performed hand hygiene before or after administering resident 9 their medication. c. At 6:47 AM, LPN 1 was observed to remove the glucometer from the medication cart. LPN 1 was observed to pick up gloves and the glucometer and enter resident 32's room. d. At 6:49 AM, LPN 1 was observed to don gloves without performing hand hygiene prior to donning the gloves and performed a blood sugar check with the glucometer on resident 32. LPN 1 doffed the gloves prior to exiting the room and did not perform hand hygiene. e. At 6:56 AM, LPN 1 was observed to touch her computer keyboard, the computer mouse, the top of the medication cart, and the medication cart keys. LPN 1 was observed to begin removing medication packs for resident 32 from the medication cart and place them into a medication cup. f. At 7:04 AM, LPN 1 was observed to hand the medication cup to resident 32. Resident 32 requested additional pain medication and LPN 1 was observed to take the medication cup back from the resident, pour the cup of Miralax down the sink that the resident refused and exited the room. It should be noted that LPN 1 had not performed hand hygiene before preparing resident 32's medication or after taking the medication cup back from resident 32. g. At 7:08 AM, LPN 1 was observed to touch her computer keyboard, the computer mouse, the top of the medication cart, the narcotic binder, and the medication cart keys. LPN 1 was observed to place medication into resident 32's medication cup. LPN 1 was observed to enter resident 32's room and hand resident 32 her medication cup. It should be noted that LPN 1 did not perform hand hygiene prior to administering resident 32 her medication. On 3/3/26 at 7:36 AM, an interview was conducted with LPN 1. LPN 1 stated that she should perform hand hygiene before and after preparing medications for residents. LPN 1 stated that there usually was hand sanitizer on the cart, but she was unable to locate the hand sanitizer. On 3/3/26 at 8:50 AM, an interview was conducted with the DON. The DON stated that she expected nursing staff to wash their hands when performing medication pass whenever they thought about it and in between patients. The DON stated that there should be hand sanitizer on the medication cart and there was hand sanitizer on the walls in the hallways for nursing staff to use.

Based on observation, interview, and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, for 1 out of 29 sampled residents, a resident that did not have exit seeking behavior had a wander guard put on. Resident identifier: 32. Findings included:Resident 32 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety, metabolic encephalopathy, and mild cognitive impairment.On 11/28/25, an Elopement/Wandering Assessment was completed. Resident 32 was documented as a low wander risk, resident 32 had no elopement history, and was alert and oriented.On 12/19/25 at 12:43 PM, a Nurse Practitioner / Physician Assistant Progress Note documented . She has no hallucinations/delusions, no violent behavior, no verbal threating [sic] or screaming behavior and she does not try to wander out of the facility.On 1/26/26 at 2:53 PM, a Nursing Note documented Pt [patient] had a fall in room in early AM had hit left side head on footboard, pt has small bruise right side temple area . Pt is on abx [antibiotic] for UTI [urinary tract infection] and has baseline confusion. Wander guard put on to prevent exiting faculty [sic] due to wandering around, will often forgether [sic] walker. Wander guard to left ankle. Husband and MD [Medical Director] aware of fall and ankle guard. Neuro [neurologicals] check normal limits.On 1/29/26 at 4:08 PM, a Nursing Note documented . Pt has confusion at baseline but has had increased confusion being treated for UTi has foley cath [catheter] .On 1/31/26 at 1:52 PM, a Daily Skilled Note documented . resident asked to have the wander guard removed today. Reminded her that she needed it on because she was still a little confused due to the UTI. Informed her it was to keep her safe. She agreed that was a good idea and stated it was okay then to leave it on.It should be noted that resident 32 completed the antibiotic for the UTI on 2/1/26.A care plan focus initiated on 2/1/26 documented Elopement risk/wanderer r/t [related to] impaired cognition, wandering. The interventions included, document wandering behavior and attempted diversional interventions, monitor wander guard placement, and provide structured activities: toileting, walking, reorientation strategies.It should be noted that resident 32 had no documented wandering behavior.On 2/23/26 at 2:01 PM, a Minimum Data Set (MDS) Note documented . She does not wander and does not reject cares.On 2/27/26, a quarterly MDS assessment documented that resident 32 had a Brief Interview for Mental Status (BIMS) score of 10. A BIMS score of 8 to 12 would indicate moderate cognitive impairment.On 3/1/26, an Elopement/Wandering Assessment was completed. Resident 32 was documented as a low wander risk, resident 32 had no elopement history, and had intermittent confusion. On 3/2/26 at 12:19 PM, an interview was conducted with resident 32. Resident 32 was asked about the wander guard bracelet that was observed on her left ankle. Resident 32 appeared excited and asked if I was going to take the wander guard off. The nurse walked in during the interview to get resident 32's blood glucose reading and stated to resident 32 that the wander guard had to stay on.On 3/2/26 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 32's confusion would go up and down. LPN 2 stated when resident 32 had the UTI, resident 32 walked by the nurses station, and out the front door. LPN 2 stated that resident 32 did not particularly have a history of wandering up until that one night. LPN 2 stated that resident 32 had more confusion with the most recent admission.On 3/3/26 at 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the staff did not do much for resident 32 because she was required only supervision with cares. CNA 1 stated that staff did catheter cares for resident 32. CNA 1 stated that resident 32 was ambulatory and ambulated pretty well. CNA 1 stated that resident 32 did not exit seek. CNA 1 stated that resident 32 may have had exit seeking behaviors before she started working at the facility but she was not aware of any. CNA 1 stated that resident 32 did get confused sometimes. CNA 1 stated that yesterday resident 32 was more confused but not exit seeking. On 3/4/26 at 7:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 32 would get confused and she was a higher risk. The DON stated the wander guard was on just in case and resident 32 had the potential to wander. The DON stated the facility would try to get the residents out to a different facility if they were a wander risk. The DON stated that resident 32 would wander up to the front doors.The facility policy Elopement / Unsafe Wandering was reviewed. PolicyIt is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.Definitions:Wandering is the random or repetitive locomotion and can be either goal directed or non-goal directed/aimless.Procedure1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an Elopement/Wandering Evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempts to elope.2. Residents with high risk factors will be identified as At Risk and will have an individualized care plan developed that includes measurable objectives and timeframes.a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk.b. Interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering.3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions.The policy had a revision/review date of 4.2025

Based on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 2 out of 29 sampled residents, a resident's tube feeding did not have the formula bag labeled with the correct date and time of the formula preparation, or the nurse's initials who initiated the infusion. In addition, a resident's tube feeding was not labeled with all of the required information. Resident identifiers: 4 and 44. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, protein-calorie malnutrition, and dysphagia. On 3/1/26 at 10:27 AM, an observation was made of resident 4's tube feeding formula. The formula infusing was Jevity 1.2. There was a written date of 3/1/26 at 0940 [9:40 AM]. Resident 4 and his family member were interviewed. Resident 4's family member stated resident 4 was receiving a Two calorie formula for weight gain and the tube feeding ran for 14 hours during the day. A physician's order dated 2/25/26, revealed Start at 0500 [5:00 AM] stop at 2000 [8:00 PM] Start feeding Run Two Cal [calorie] enteral feed at 90ml/hr. [milliliter per hour] x 14 hours tv [total volume] +1190 Water flushes 80ml/q2h [milliliter per every two hours] with a water flush of 65ml/hr. times 14 hours TV=910 AND at bedtime for Start at 0500 stop at 2000 Stop feeding 2000. On 3/1/26 at 3:31 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was aware that resident 4's tube feeding was 1.2 calorie instead of the Two cal, so she changed it to the Two cal. RN 1 stated she was not sure what time she changed the formula from Jevity 1.2 calorie to the Two cal formula. RN 1 observed the tube feeding formula infusing into resident 4. It was observed to be Two cal with the date of 3/1/25 at 0800 [8:00 AM] written on the formula container. RN 1 stated she must have changed it at 8:00 AM, after the surveyor was in the room. RN 1 stated she did not hang the Jevity 1.2 formula and it should have been started at 5:00 AM. It should be noted, the Jevity 1.2 was observed to be infusing on 3/1/26 at 10:27 AM, and the Two cal was not infusing at that time even though it was documented as started on 3/1/26 at 8:00 AM. On 3/3/26 at 12:48 PM, an interview was conducted with RN 2. RN 2 stated resident 4 needed his tube feeding infusing for 14 hours at 90 ml/hr. RN 2 observed the tube feeding and there was a date of 3/3/26 at 0500. There was no other written information on the tube feeding formula. 2. Resident 44 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dysphagia, and protein calorie malnutrition. On 3/1/26 at 12:13 PM, an observation was made of resident 44's tube feeding formula. The tube feeding formula was labeled 14 a 3/1. The pump was set at a continuous rate of 45 ml/hr. On 3/3/26 at 6:52 AM, an observation was made of resident 44's tube feeding formula. The tube feeding formula was labeled 14 A 3/3/26 0445 [4:45 AM]. A physician's order dated 2/13/26, documented Enteral Feed Order every shift Jevity 1.2 45ml/hr, x 24 hrs [hours] Water flush 150ml Q4 hrs [milliliter every four hours]. On 3/3/26 at 7:46 AM, an interview was conducted with RN 2. RN 2 stated that she would change and throw out the old feeding stuff daily. RN 2 stated that she would label the tube feeding formula with the date, time, room number, patient's name, signature of the nurse, name of formula, and dose of the formula. RN 2 stated that on the water bag she would put the date, time, patient 's name, nurse signature, and the rate of the water to be given. On 3/4/26 at 7:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the tube feeding formula was already labeled. The DON stated that she would expect the nurse to write on the tube feeding formula the date, time, and room number. The facility policy Infection Control Policy / Procedure was reviewed. Section: Resident Care Subject: Tube Feeding – Nasogastric or Gastrostomy . PROCEDURES: Pre-mixed feedings are preferable, the following procedure will be followed with all enteral (tube) feedings. 2. Prepare feeding using clean technique according to the physician's order. A. Label the feeding bag with the resident's name, room, date and time started, kind and strength of feeding. B. Take to the bedside. 6. Feeding container is to be labeled with time started with each new feeding. The facility policy was revised on 06/2007. Review of the Lippincott Nursing Procedures documented under Enteral Gastric, Duodenal, and Jejunal Tube Feeding for implementation to Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of who prepared, hung and checked the enteral formula against the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY–NOT FOR IV USE. Wolters Kluwer. Lippincott Nursing Procedure. Ninth Edition. Philadelphia, PA. (2023), pp 296.

Based on observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 29 sampled residents, a resident with a bilevel positive airway pressure (BiPAP) machine was unable to use the machine due to missing parts. Resident identifier: 5.Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease, asthma, and obstructive sleep apnea.On 3/1/26 at 9:22 AM, an interview was conducted with resident 5. Resident 5 was observed with an oxygen concentrator. Resident 5 stated that he had been using oxygen for about a month. Resident 5 stated he had not used his BiPAP machine since he admitted to the facility. A BiPAP machine was observed on resident 5's bedside nightstand. Resident 5 stated the BiPAP machine was missing a special adapter to hook up the oxygen. Resident 5 stated they would prefer he used the BiPAP while sleeping and not the oxygen. Resident 5 stated he ordered the adapter from the Veterans Affairs (VA) but he had not seen it.Resident 5's medical record was reviewed. There were no progress notes, physician orders, or a care plan that documented the BiPAP machine.On 1/6/26, an Inventory Of Personal Effects did not include a BiPAP machine.On 3/3/26 at 10:50 AM, an interview was conducted with Registered Nurse (RN) 3 and Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident was admitted with or needed a BiPAP machine she would make sure there was a physician order and if not she would get the physician order from the provider. LPN 1 stated that she would make sure the resident had a diagnosis for the BiPAP machine. RN 3 stated that she would look at the BiPAP machine and make sure it was safe, the set up was correct, the cords were good, and the BiPAP machine was clean. RN 3 stated that staff would need to wash the BiPAP machine mask daily. RN 3 stated that resident 5 had a nebulizer but she was not aware of a BiPAP machine.On 3/3/26 at 10:57 AM, an observation was conducted of resident 5's room with RN 3. RN 3 observed the BiPAP machine on resident 5's bedside nightstand next to the nebulizer machine. Resident 5 stated that he needed the adapter for the air. Resident 5 stated he brought the BiPAP machine with him on admission to the facility. Resident 5 stated he had ordered the adapter twice from the VA to be delivered to the facility. Resident 5 stated that he really really needed the adapter. On 3/3/26 at 11:27 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC). The ADON stated that resident 5 admitted from home without orders for the BiPAP machine. The ADON stated they did not know resident 5 had a BiPAP machine. The ADON stated that resident 5 wanted to start using the BiPAP machine. The ADON stated they were going to get resident 5 set up at the sleep center to get the adapter for the BiPAP machine. The ADON stated that resident 5 had been working with the VA on his own to get the adapter. The RNC stated that if the resident had a diagnosis they would usually try to set the resident up with something.

Based on observation, interview and record review it was determined, for 2 of 14 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice. Specifically, two residents received their morning medications late. Resident Identifiers: 12 and 13. Finding Included: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, chronic respiratory failure with hypoxia, cognitive communication deficit, mild cognitive impairment of uncertain or uncertain or unknown etiology, chronic pain syndrome, and personal history of pulmonary embolism. On 9/24/24 at 10:32 AM, an observation was made of Registered Nurse (RN) 2 during the morning medication pass. RN 2 was observed to be preparing resident 12's medications which consisted of gabapentin, oxycodone, clopidogrel, vitamin B12, cyclobenzaprine, multivitamin, oxybutynin extended release, vitamin C and D, Tylenol and eye drops. Resident 12 was observed to receive their medication at 10:40 AM. Resident 12's physician orders were reviewed and documented the scheduled morning medications were due to be given from 7:00 AM - 9:00 AM. On 9/24/24 at 10:45 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they were a little late with medications because they had people stop them and ask for stuff. RN 2 stated medication pass was from 6 am to 10 am. RN 2 stated they did have people they could ask to help them with med pass but had not done so. RN 2 stated during medication pass, the computer system would alert the staff regarding medication timing using a color system. RN 2 stated if a resident's name was in red then it meant the medication was over due; if the residents name was in yellow then it meant the medication was due; if the residents name was in green then it meant the medication was given. RN 2 stated they still had 5 more residents to give medications to. It was observed that all 5 of the residents names were in red. 2. Resident 13 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, longstanding persistent atrial fibrillation, paroxysmal atrial fibrillation, and other thrombophilia. On 9/24/24 at 10:51 AM, an observation was made of Licensed Practical Nurse (LPN) 2 during morning medication pass. LPN 2 stated they were finishing up with their current resident and had one more resident left with morning medications. At 11:03 AM, LPN 2 was observed preparing resident 13's medications which consisted of metoprolol, diltiazem, apixaban, allopurinol, senna plus and MiraLAX. Resident 13 was observed receiving their medications at 11:09 AM. A follow up interview was conducted with LPN 2. LPN 2 stated morning medications were scheduled to be given from 7:00 AM - 9:00 AM but they were allowed to administer medication an hour before to an hour after the scheduled times. Resident 13's physician orders were reviewed and documented the scheduled morning medications were due to be given from 7:00 AM - 9:00 AM. On 9/24/24 at 12:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they had a flex med pass which allowed flexibility for medications to be given an hour prior to an hour after they were scheduled. The DON stated it was not uncommon for the nurses to ask for help if they were behind on med pass. The DON stated if a resident name appeared red during med pass, then it meant the medications were late. The DON stated they were not aware of any nurses requesting assistance with medication pass today. The DON stated if medications were given outside of the flex times, they expected the nurses to notify the provider and write a progress note about giving the medication late.

Based on observation, interview and record review, it was determined for 1 of 14 sampled residents, that the facility did not ensure that a resident who was assessed to be an elopement risk received adequate supervision to prevent accidents. Specifically, a resident did not have adequate interventions in place to mitigate the risk for elopement for 4 days following an elopement risk assessment that determined the resident was a high elopement risk. Resident identifier 6. Findings included: On 3/16/24, resident 6 was admitted to the facility with the diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, history of transient ischemic attack and cerebral infarction without residual deficits, and cognitive communication deficit. Resident 6's medical record was reviewed on 9/24/24. On 3/16/24, an elopement assessment was conducted, the document indicated resident 6 was a high wander risk. The assessment stated the resident had dementia and had no history or current behaviors of wandering. [It should be noted that this was an initial assessment, and the facility did not have historical wandering behavior documented for resident 6.] On 3/19/24, a second elopement assessment was conducted and indicated resident 6 continued to be a high wander risk. The assessment stated the resident had dementia, was disoriented, had a 1-2 times elopement history in the past 6 months, made statements of desire to exit the facility, had aimless wandering with the potential to go outside, had active exit seeking behavior, wander behavior was worse in the past 90 days, and was ambulating independently with an assistive device. A review of resident 6's care plan was conducted, wander risk and elopement prevention interventions were not added to the care plan following the elopement assessments conducted on 3/16/24 and 3/19/24. On 3/23/24, form 358 was submitted at 5:20 pm for elopement that stated the Resident was found approximately 10 feet past our property line heading north across [a local street]. [A staff member] immediately went to and redirected her back to the building. She was assessed for any injury, none found. Increased supervision. A referral was made to another facility that has a memory care unit that can better care for her needs. She will be transferred as soon as possible. The resident eloped from the facility at approximately 4:15 pm, the staff was aware of the elopement at 4:20 pm. Administrator was notified at 4:30 pm. On 3/24/24, the care plan was updated by Director of Nursing (DON), and initiated one on one supervision, initiate Anti-anxiety medication use r/t [related to] xanax Adjustment issues, confusion, and implemented interventions Monitor/record occurrence of for target behavior symptoms pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.), and Non-pharmacological interventions done: back rub, redirection, speak to/approach in a calm manner, reposition, offer snacks/fluid/milk, assess for pain, provide a quiet environment, encourage to express feelings, take to activities, provide reassurance. [It should be noted that care plan intervention were not added and implemented until after resident 6 eloped from the facility.] On 9/24/24 at 12:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was exit seeking, we would have put the resident on a one-to-one supervision, locked the doors to ensure the door alarms when pressed open, provided frequent checks, and seek different placement for the resident. The DON stated for resident 6, it sounded like the provider thought the resident wanted to go home because the resident was anxious. I know she wanted to go home to be with her boyfriend. The DON was not able to produce documentation to demonstrate that wander precautions were in place after the resident was identified to be at a high risk for wandering and elopement following the 3/16/24 and 3/19/24 elopement assessments.

Based on observation, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the kitchen, dry storage room, and walk-in freezer were open to air, and food items in the snack cooler and walk-in refrigerator were not labeled and dated. Findings include: On 1/8/24 at 6:59 AM, an initial walk-through of the kitchen was conducted. In the food preparation area within the kitchen a bulk container with oats was uncovered and open to air, a bulk container with brown sugar was uncovered and open to air. In the snack cooler, a container of low fat cottage cheese was not dated as to when it was opened. In the dry storage room, a container of white sugar was open to air. In the walk-in refrigerator, a container with an unknown orange colored pureed substance was covered but was not labeled or dated. In the walk-in freezer, a box of cinnamon rolls was open to air, a box of breadsticks was open to air, a box containing beef patties was open to air. In a stainless steel pan, several zip-seal sandwich bags containing bacon, egg, and cheese bites, onion rings, corn ribz, cinnamon swirl toast and Brussels sprouts were labeled but not dated. According to Foodsafety.gov, a subsection of the FDA (food and drug administration), The guidelines for freezer storage are for quality only-frozen foods stored continuously at 0 F (-18 C) or below can be kept indefinitely. Guidelines included in Cold Food Storage Chart provide guidance that, depending on the food item, foods can be safely frozen for 1 month to 12 months. The USDA (United States Department of Agriculture states, Proper packaging helps to maintain quality and prevent freezer burn .Freezer burn does not make food unsafe, merely dry in spots. It appears as grayish-brown leathery spots and is caused by air coming in contact with the surface of the food.

Based on observation and interview it was determined, for 1 of 26 sampled residents, that the facility did not ensure that drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, a nurse was observed to place an unused portion of a medication back inside the pharmacy dispensed blister pack and tape the back closed. Resident identifier: 40. Findings included: Resident 40 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, severe sepsis, fracture of right foot, type II diabetes mellitus, acute kidney failure, hyperkalemia, major depressive disorder, hyperlipidemia, myelodysplastic disease, thrombocytosis, and hypertension. On 1/10/24 resident 40's medical records were reviewed. On 12/11/23, resident 40's physician ordered Aripiprazole 10 milligram (mg), give 0.5 tablet by mouth in the morning for chronic recurrent major depression. On 1/10/24 at 9:21 AM, an observation was made of Registered Nurse (RN) 2 during morning medication administration. RN 2 was observed to dispense a 10 mg tablet of Aripiprazole from a pharmacy blister pack and cut the tablet in half. RN 2 then took the unused 1/2 tablet of Aripiprazole and placed it back inside the blister pack. RN 2 then taped the back of the blister pack closed with plastic medical tape. An immediate interview was conducted with RN 2. RN 2 stated that she would normally place pills back into the blister pack if they were unused and tape the pack closed, especially if they were narcotics. RN 2 stated that she could also dispose of the unused portion of the medication and could have a second nurse verify the wasted medication. Review of the Nursing 2022 Drug Handbook documented under Strategies for reducing error rates that dispensing medications in unit-dose or unit-of-unit packaging helped to reduce medication administration error rates. Wolters Kluwer (2022). Nursing 2022 Drug Handbook. 42nd Edition. p 20. On 1/10/24 at 10:14 AM, an interview was conducted with the Corporate Resource Nurse (CRN) and Director of Nursing (DON). The CRN stated that she would provide RN 2 with education immediately. On 1/10/24, the CRN provided a One on One in-service that was conducted with RN 2. The in-service contained information on the five rights of medication administration. The in-service documented, It is never appropriate to tape a medication back into the bubble pack.

Based on observation and interview it was determined that the facility did not ensure that the medical records on each resident were complete and accurately documented. Specifically, the nurse was witnessed to alter the timestamp of blood sugar checks according to approximations of when the task was completed. Findings included: On 1/10/24 at approximately 9:32 AM, an observation was made of Registered Nurse (RN) 2 during morning medication administration. RN 2 was observed filling out the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for 2 unidentified residents. RN 2 was heard to say that she completed a task about 30 minutes ago and then was witnessed to enter a prior timestamp into the electronic medical record. RN 2 was then heard to say that she completed a second task approximately an hour ago and then was witnessed to enter a prior timestamp into the electronic medical records. On 1/10/24 at approximately 10:40 AM, an interview was conducted with RN 2. RN 2 stated that she was entering the time stamp for blood sugar checks and not medication administration. RN 2 stated that the electronic medical records only allowed her to modify the timestamp on blood sugar checks. RN 2 stated that the system would not allow her to modify the timestamp for medication administration. RN 2 stated she could not recall who the residents were that she entered the timestamp for the blood sugar checks. RN 2 stated that she usually was so busy that she would complete the blood sugar check and then document it at a later time. An immediate interview was conducted with the Corporate Resource Nurse (CRN) and Director of Nursing (DON). The CRN and DON confirmed that the eMAR and eTAR would not allow a user to alter the timestamp of medication administration. The DON stated that the eMAR would automatically timestamp the medication administration. The DON stated that it was not acceptable to change the timestamp of any task completed.

Based on observation, interview and record review it was determined, for 4 of 26 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident suspected of having an infection with Clostridium difficile (c-diff) was not placed on transmission based precautions (TBP), staff were observed to enter a room on contact precautions without donning the required Personal Protective Equipment (PPE), a nurse was witnessed to handle medications bare handed during medication administration and to administer a medication to a resident after it had been dropped into the bottom of the medication drawer, and hand hygiene was not performed during meal tray delivery. Resident identifiers 4, 16, 40, and 106. Findings included: 1. On 1/08/24 at 10:19 AM, an interview was conducted with resident 4. Resident 4 stated that she was not feeling well, was nauseous, and that she had diarrhea. Resident 4 shared a room with another resident. On 1/09/24 at 1:00 PM, resident 4 was observed to be residing in a different room than the day before. Resident 4 was located in a room with a stop sign on the door and a PPE cart was located outside of the room. An immediate interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the isolation cart outside of resident 4's room was for potential c-diff. LPN 1 stated that the stool sample was sent this morning, but thought it was ordered yesterday. LPN 1 stated that resident 4 had an episode of diarrhea this morning and the wound nurse collected the stool sample. LPN 1 stated that he noted a distinct odor to the stool and it was not a typical diarrhea smell. LPN 1 stated that if they suspected a resident of having c-diff they automatically placed that resident on isolation precautions until they received the results back. On 1/9/24, resident 4's medical records were reviewed. On 1/7/24 at 4:15 PM, resident 4 had an order for a c-diff sample to be sent due to diarrhea for 2 days. On 1/7/24 at 4:15 PM, resident 4 had a change in condition evaluation completed. The assessment documented that resident 4 had altered mental status and diarrhea that started on 1/6/24. The assessment documented that resident 4 had a decreased level of consciousness and was drowsy and hard to arouse. Resident has been more drowsy, hard to arouse. Able to answer a question with much prompting, but falls back asleep. The assessment also documented that resident 4 had hyperactive bowel sounds along with diarrhea with mucus and blood noted. The assessment documented that the provider was notified on 1/7/24 at 11:00 AM. The assessment documented the recommendations from the provider were, Discontinue scheduled Tramadol/Clonzepam. Check for Cdiff. Hold lasix dose for tomorrow d/t [due to] diarrhea. STAT [immediate] CBC [complete blood count] and CMP [comprehensive metabolic panel]. Liquid diet for dinner tonight and breakfast tomorrow. On 1/8/2024 at 1:24 PM, the provider progress note documented, Muscle weakness/less lethargic with med changes yesterday: Therapy as tolerated today. She seems to be going to session. Awaiting CBC CMP results. She had diarrhea: So getting her into isolation for now as awaiting lab to check for Cdiff and CBC CMP as above. Even though she told nurse diarrhea was from drinking OJ [orange juice] which she reports causes her diarrhea. We will see. On 1/10/24 at 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a resident with suspected c-diff should be in a room on their own until they determined that they did not have it. The DON stated that the resident would also be on contact precautions. The DON stated that the resident should be isolated away from other residents so they did not expose them. 2. On 1/8/24 at approximately 6:40 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] had a sign posted on the door for contact precautions and a PPE cart was located outside the room. The PPE cart contained Microkill wipes, surgical masks, and gowns. On 1/8/24, the following observations were made during breakfast delivery by Certified Nurse Assistant (CNA) 2: a. At 7:35 AM, the first meal tray was delivered to room [ROOM NUMBER]A, no hand hygiene (HH) was performed. b. At 7:37 AM, the meal tray was delivered to 22A, no HH was performed. c. At 7:37 AM, the meal tray was delivered to room [ROOM NUMBER]B, no HH was performed. d. At 7:39 AM, the meal tray was delivered to room [ROOM NUMBER]A, no HH was performed. e. At 7:40 AM, the meal tray was delivered to room [ROOM NUMBER]B. CNA 2 moved the bedside table and positioned it over the resident, no HH was performed. f. At 7:42 AM, the meal tray was delivered to room [ROOM NUMBER]A. CNA 2 moved the bedside table, no HH was performed. g. At 7:43 AM, the meal tray was delivered to room [ROOM NUMBER]B. CNA 2 opened the blinds, no HH was performed. h. At 7:43 AM, the meal tray was delivered to room [ROOM NUMBER]B. CNA 2 touched the bedside table, no HH was performed. i. At 7:44 AM, the meal tray was delivered to room [ROOM NUMBER]A. CNA 2 moved the mug and items on the bedside table, assisted the resident to a sitting position, touched the bed remote, touched the bedside table, and removed the cover from the plate. CNA 2 handed the utensils and plate to the resident, and spread jelly on the toast. No HH was performed. j. At 7:47 AM, the meal tray was delivered to room [ROOM NUMBER]A, no PPE was donned prior to entering the room, and no HH was performed upon exit. k. At 7:48 AM, the meal tray was delivered to room [ROOM NUMBER]B, no PPE was donned prior to entering the room, and no HH was performed upon exit. l. At 7:48 AM, the meal tray was delivered to room [ROOM NUMBER]A, no HH was performed. m. At 7:49 AM, the meal tray was delivered to room [ROOM NUMBER]B. CNA 2 adjusted and moved the bedside table, no HH was performed. n. At 7:56 AM, the meal tray was delivered to room [ROOM NUMBER]B. CNA 2 adjusted the bedside table and opened the milk carton, no HH was performed. o. At 7:56 AM, the meal tray was delivered to room [ROOM NUMBER]B, no HH was performed. p. At 7:57 AM, the meal tray was delivered to room [ROOM NUMBER]A, no HH was performed. q. At 7:58 AM, the meal tray was delivered to room [ROOM NUMBER]. CNA 2 adjusted the bedside table, and touched the OJ cup, no HH was performed. r. At 7:59 AM, the meal tray was delivered to room [ROOM NUMBER]B, no HH was performed. s. At 8:00 AM, the meal tray was delivered to room [ROOM NUMBER]A, no HH was performed. t. At 8:01 AM, the meal tray was delivered to room [ROOM NUMBER]B, no HH was performed. On 1/08/24 at 8:09 AM, an interview was conducted with CNA 2. CNA 2 stated that they should perform HH after delivery of so many trays but was not able to state how many. CNA 2 stated she needed to find out what TBP were for in room [ROOM NUMBER]. CNA 2 was observed to enter the Director of Nursing's (DON) office. CNA 2 exited the office and reported that the TBP in room [ROOM NUMBER]B was for MRSA [methicillin-resistant staphylococcus aureus] in the urine. CNA 2 stated she was supposed to donn a gown, gloves, and mask before entering the room. CNA 2 stated she forgot to do this when she entered the room to deliver the breakfast tray. CNA 2 stated that she should be performing HH after each meal tray delivery and was just told this by the DON. 3. On 1/10/24 at 9:21 AM, an observation was made of Registered Nurse (RN) 2 during morning medication administration. RN 2 was observed to dispense all of resident 40's medications into her bare hands and then placed them into a medication cup. RN 2 was observed to administer insulin to resident 40 without gloves donned. RN 2 was observed to dispense resident 40's Aripiprazole tablet into her bare hands and placed it on top of the medication cart while she located a pill cutter. RN 2 was observed to administer all of resident 16's morning medication into her bare hands. RN 2 was observed to touch her hair, the medication cart, and the keys to the medication cart while handling medications with her bare hands. RN 2 was observed to dispense resident 106's vitamin B complex tablet into her hands. The tablet dropped into the opened medication drawer. RN 2 pulled the tablet from the bottom of the drawer and administered it to resident 106. An immediate interview was conducted with RN 2. RN 2 stated that she started the medication administration with gloves donned, but her hands became dry and chapped so she stopped using them. RN 2 stated that she sanitized her hands between each resident administration. RN 2 stated that if a medication was dropped into the medication drawer it was still acceptable to administer that medication. RN 2 stated that she normally handled resident medication with bare hands because if she dispensed them directly into the cup they sometimes fell out. RN 2 stated that she had worked at over 20 facilities and never had an issue with dispensing medications into her bare hands. On 1/10/24 at 10:14 AM, an interview was conducted with the Corporate Resource Nurse (CRN) and the Director of Nursing (DON). The CRN and DON were informed of the medication administration observations. The CRN stated that she would provide RN 2 with education immediately. The DON confirmed that it was not acceptable practice to handle medications with bare hands. On 1/10/24, the CRN provided a One on One in-service to RN 2. The in-service contained information on the five rights of medication administration. The in-service documented, It is not appropriate to touch a medication with your bare hand. If you have to touch the medication, put on a glove and then discard the glove once done touching the medication. If you drop a pill on any surface other than the medication cup you need to discard the medication and get a new. 22992 4. On 1/9/24, the following observations were made during the lunch meal in the main dining room: a. At 12:30 PM, a resident took some garbage and soiled dishes to the serving window and left them on the metal counter area. At 12:58 PM, CNA 3 approached the serving window, and prepared a cup of tea with sugar directly next to where the soiled dishes had been placed. b. At 1:00 PM, CNA 3 picked up a resident's garbage and placed it on top of his plate. CNA 3 took the soiled plate to the serving window. CNA 3 then returned and repositioned a second resident in his wheelchair by touching the resident and the wheelchair handles. CNA 3 then picked up a third resident's plate and garbage and placed the soiled items in the serving window. CNA 3 then left the dining room. At no time was CNA 3 observed to perform hand hygiene after touching multiple residents' soiled items and equipment. 43212 Resident 38 was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of right foot, acute systolic heart failure, hypokalemia, chronic kidney disease, morbid obesity and deep vein thrombosis in upper extremity. On 1/8/24 at 8:23 AM, an observation was made of resident 38's room. A Personal Protective Equipment (PPE) station was located outside the door and the door had a sign indicating that one of the residents was on contact precautions. At the same time, Registered Nurse (RN) 3 exited the room. An interview was conducted. RN 3 stated that resident 38 was on contact precautions because he had MRSA (Methicillin-resistant Staphylococcus Aureus) and VRE (Vancomycin-resistant enterococcus) bacteria in his urine. Shortly after the interview, the Director of Nursing (DON) came to the door and removed the sign on the door and the PPE cart. She stated the resident was no longer on contact precautions. Resident 38's medical records were reviewed. On 12/21/23 at 4:05 PM, resident 38's progress notes revealed, Resident called me and said he was in excruciating back pain. Given Tramadol. Resident reports he has kidney stones. Asked him to give the Tramadol some time to work, but he states it's not strong enough. Resident said he feels like there is something wrong and he wants to go to the hospital to be evaluated. Non-emergent transport called and resident taken to [NAME] Regional. Message sent to provider. On 12/21/23 at 9:29 PM, resident 38's progress note revealed, Resident returned from hospital via EMS (emergency medical services). Resident is doing well. Pain is controlled at present. Resident was found to have large obstructing stones on the L (left)-which may be old/chronic. He is to follow-up with Urologist ([physicians name] was the one [resident's name] saw in the ER(emergency room ). He is also to follow-up with nephrologist [physicians name removed]. We are to let them know that resident has high calcium and uric acid levels. Resident does appear to have a UTI (urinary tract infection)-cultures were sent. Resident should drink plenty of water. Antibiotics were started this evening. Resident is encouraged to ambulate more. Lortab, Tizanidine, and Cefdinir started. On 1/2/24 at 1:38 PM, a nursing progress note revealed, Urine results received from hospital. Resident's urine positive for MRSA an VRE. Hospital recommended resident be started on Macrobid 100 mg PO bid x 5 days. Provider notified and agreed to order. Resident notified of results, abx order, and being placedon contact precautions. Resident is his own responsible party and stated he would notify his own family of results. First dose of macrobid given. Resident placed on contact precautions. On 1/2/24 at 1:49 PM, a change of condition progress note revealed that urine results were received related to resident 38's UTI on 12/21/23. The Nurse Practitioner was notified, and the resident was notified. The resident stated he would notify his parents. Culture and sensitivity results were not found in the resident's medical record. Resident 38 remained on contact precautions from 1/2/24 until 1/8/24. [Note: It should be noted that resident 38's culture and sensitivity was not obtained from the hospital to confirm the UTI with related effective antibiotics until 1/2/24, which was 13 days after he went to the hospital with symptoms. Resident 38 was not on contact precautions during this time, and increasing risk of transmission during this time.] On 1/10/24 at 2:48 PM, an interview was conducted with RN 2. RN 2 stated when a lab test was done at the hospital, specifically a urinalysis, the hospital would call or fax over the results if they were significant. RN 2 stated the lab usually called. RN 2 stated if results were not received, for a culture and sensitivity, the nurse would call and obtain the results. RN 2 stated if the results had not come back and her shift was over, she would pass the information on to the on-coming nurse so it could be followed up on. RN 2 stated if a resident came back from the hospital with a prescription or orders, the nurse would have to let the provider know that the hospital had ordered an antibiotic. RN 2 stated if a urinalysis was positive, the hospital would culture it there, and would call the facility when the results came back. RN 2 stated the reason it was important to obtain the culture and sensitivity result was for antibiotic stewardship. RN 2 stated, you can just guess what antibiotic to start someone on, but once the results are in, you an put the right antibiotic in place to avoid additional problems. On 1/11/24 at 11:15 AM, an interview was conducted with the DON. The DON stated the culture and sensitivity obtained on 1/2/24 was not loaded into the resident's medical record yet. The DON stated the expected time for a culture and sensitivity to come back was unknown and depended on when the test was done and who the provider was. The DON stated sometimes it took 72 hours. The DON stated if they did not get a result they would usually request it. The DON stated that a urologist saw resident 38 in the emergency room and the results likely were reported to the urologists office. The DON stated it was the nurse's responsibility to find out what the test results were if they did not come back. The DON also stated the delay could have been because of the holidays. On 1/11/24 at 11:15 AM, an interview was also conducted with the Corporate Resource Nurse (CRN) who stated if someone went to the emergency room , the facility would request lab results, but when the results came back was out of their control.

Based on observation, interview and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that a resident who self-administered medications was evaluated to determine that the practice was clinically appropriate. Specifically, a resident reported that they self administered an albuterol inhaler as needed and the facility did not evaluate the resident's ability to safely administer the medication. Resident identifier 37. Findings included: Resident 37 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, acute and chronic respiratory failure, gout, gastrointestinal hemorrhage, cardiac arrhythmia, hyperkalemia, end stage renal disease, hypertension, major depressive disorder, and non-ST elevation (NSTEMI) myocardial infarction. On 1/8/24 at 9:07 AM, an interview was conducted with resident 37. Resident 37 stated that she had COVID a couple of weeks ago. Resident 37 stated that she still had a productive cough that was bad in morning until she loosened up the mucous and coughed it out. Resident 37 stated that she took her inhaler and it helped. Resident 37 retrieved from the bedside table drawer an albuterol inhaler. Resident 37 stated that she was not asthmatic, but had chronic obstructive pulmonary disease (COPD) from smoking. On 1/9/24 resident 37's medical records were reviewed. On 8/28/23, the provider ordered for resident 37 Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) micrograms (MCG)/actuation (ACT), 2 puff inhale orally every 4 hours as needed for shortness of breath. No documentation could be found of a self administration assessment for resident 37's use of the albuterol inhaler. On 1/11/24 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she did not have any residents that kept medication at the bedside to self administer. RN 1 stated that if they wanted to do that they would need to fill out a self administration form and it would have to go to the provider for approval. RN 1 stated that resident 37 had an order for Albuterol every 4 hours as needed. On 1/11/24 at 11:07 AM, the Corporate Resource Nurse (CRN) stated that she could not find a self administration form for the Albuterol and that she would go and assess resident 37 to have it at the bedside for self administration.

Based on interview and record review it was determined, for 1 out of 26 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, a resident requiring assistance with bathing was not provided regular showers or bed baths. Resident identifier 37. Findings included: Resident 37 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, acute and chronic respiratory failure, gout, gastrointestinal hemorrhage, cardiac arrhythmia, hyperkalemia, end stage renal disease, hypertension, major depressive disorder, and non-ST elevation (NSTEMI) myocardial infarction. On 1/08/24 at 8:54 AM, an interview was conducted with resident 37. Resident 37 stated that she was provided a shower on Saturday, and prior to that she had one bed bath in two weeks. Resident 37 stated that they scheduled her shower in the morning and she liked to take it at night and they kept messing it up. Resident 37 stated that it was making her mad. Resident 37 stated that she did not refuse the shower/bed bath, she just wanted it at night. On 1/9/24, resident 37's medical records were reviewed. On 9/3/23, resident 37's Minimum Data Set (MDS) assessment documented that the resident required a two-person extensive assist for transfers, and a one-person extensive assist for dressing, locomotion on the unit, and personal hygiene. The assessment did not document how resident 37 takes their bath/shower or the support provided. Resident 37's bathing tasks for the last 30 days documented the following: a. On 12/14/23, a shower was provided. b. On 12/21/23, a sponge bath was provided. Six days had lapsed since the last documented shower. c. On 12/23/23, the resident refused. d. On 12/26/23, the resident refused. The shower sheet documented that resident 37 was not feeling well. e. On 12/30/23, a sponge bath was provided. f. On 1/6/24, a shower was provided. Six days had lapsed since the last documented shower. g. On 1/9/24, a shower was provided. The bathing task documented that resident 37 was scheduled for baths on the evening shift every Tuesday, Thursday, and Saturday. On 1/11/24 at 8:18 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 37 was scheduled for a bed bath on Tuesday, Thursday, and Saturday in the morning. CNA 1 stated that resident 37 preferred a morning bed bath because she thought it would get done more often. CNA 1 stated that they documented the shower/bed bath provided in the electronic medical records under tasks and also in a shower book. CNA 1 stated that the task documentation of NA (not applicable) was for when it was not resident 37's scheduled shower day. CNA 1 stated that after they completed a shower sheet they would place it in the binder for the CNA Coordinator to review. CNA 1 stated that the shower sheet had a section on the back side for the resident to sign if they refused a shower and they were to notify the nurse on shift of the refusal. CNA 1 stated that resident 37 needed help with washing her back side and washing her hair and she would consider her a one person moderate assist for bathing. CNA 1 stated that on days that resident 37 had dialysis she might be weaker and could require a one person extensive assist for bathing. On 1/11/24 at 8:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the CNA Coordinator would review the shower sheets and verify that a shower was provided and that the resident did not have any skin issues. The DON stated that she would provide resident 37's shower sheets. On 1/11/24 at 10:16 AM, a follow-up interview was conducted with the DON. The DON stated that they were changing the shower sheet so the nurse would attempt to have the resident shower if they refused and then document that. The DON stated that they should have documentation that the resident was either provided a shower or refused a shower. The DON stated that if it was not the residents assigned shower day they were putting NA, which the computer system automatically populated it everyday.

Based on interview and record review it was determined for 2 of 26 sample residents, the facility did not ensure that each resident was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, insulin, pain medications, and blood pressure medications were administered outside of prescribed physician parameters. Resident identifiers: 5 and 22. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included left femoral neck subcapital fracture, orthostatic hypertension, hypoxemic respiratory failure, chronic combined systolic and diastolic heart failure, diabetes mellitus, and major depressive disorder. Resident 22's medical record was reviewed from 1/8/24 through 1/11/24. Resident 22's physician orders were reviewed and included the following: a. 11/14/23 - Amlodipine Besylate 5 milligrams (mg) in the morning for a diagnosis of hypertension. The order indicated that facility staff were to hold the medication if the systolic blood pressure (BP) was less than 120. b. 12/18/23 Amlodipine Besylate 10 mg in the morning for a diagnosis of hypertension. The order indicated that facility staff were to hold the medication if the systolic BP was less than 120. c. 8/10/23 - Lisinopril 40 mg in the morning for a diagnosis of hypertension. The order indicated that facility staff were to hold the medication if the systolic BP was less than 110. d. Metoprolol Succinate extended release 50 mg in the morning for a diagnosis of hypertension. The order indicated that facility staff were to hold the medication if the systolic BP was less than 110. e. Insulin Glargine 8 units at bedtime for a diagnosis of diabetes mellitus. The order indicated that facility staff were to hold the medication if the blood sugar was less than 120. Resident 22's December 2023 and January 2024 Medication Administration Records (MAR) were reviewed. The MARs documented the following errors: a. On 12/9/23, resident 22's BP was 102/70. Per the physician's order the amlodipine, lisinopril, and metoprolol should have been held. The MAR indicated that the medications were administered. b. On 12/25/23, resident 22's BP was 118/72. Per the physician's order the amlodipine should have been held. The MAR indicated that the medication was administered. c. On 12/27/23, resident 22's blood surgar was 116. Per the physician's order the insulin should have been held. The MAR indicated that the medication was adminsitered. d. On 12/31/23, resident 22's BP was 111/62. Per the physician's order the amlodipine should have been held. The MAR indicated that the medication was administered. e. On 1/6/24, resident 22's BP was 109/65. Per the physician's order the amlodipine, lisinopril, and metoprolol should have been held. The MAR indicated that the medications were administered. f. On 1/9/24, resident 22's BP was 118/79. Per the physician's order the amlodipine should have been held. The MAR indicated that the medication was administered. g. On 1/10/24, resident 22's BP was 112/78. Per the physician's order the amlodipine should have been held. The MAR indicated that the medication was administered. On 1/10/24 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the medications listed above should have been held per the physician's orders. 43212 2. Resident 5 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, chronic kidney disease, bipolar disorder, major depressive disorder, personality disorder, anxiety disorder, muscle weakness, and encounter for orthopedic aftercare. Resident 5's medical records were reviewed. Physician orders included: a. Oxycodone HCL (Hydrochloride) oral tablet 20 mg (milligrams); Give 1 tablet by mouth every 8 hours for pain. Hold if BP (blood pressure) is less than 90/50. Start date 12/26/23. b. Oxycodone HCL oral tablet 20 mg; Give 1 tablet by mouth every 4 hours for pain. Hold if BP is less than 90/50. 12/13/23 through 12/26/23. c. Oxycodone HCL oral tablet 15 mg; Give one tablet by mouth every 4 hours for pain. Hold if BP is less than 90/50. 12/4/23 through 12/13/23. d. Oxycodone HCL oral tablet 15 mg; Give one tablet by mouth two times a day for pain for 7 days. Provider to re-evaluate in 7 days. 11/29/23 through 12/3/23. Resident 5's Medication administration (MAR) records were reviewed: On 12/9/23 at 7:39 PM, resident 5 was provided 15 mg of Oxycodone HCL. The MAR revealed resident 5's pain level was 8/10 indicating severe pain based on pain monitoring instructions. Resident 5's blood pressure was documented as 85/49. Resident 5's legs were elevated. Additional interventions provided included low light, relaxation and distraction. Progress notes were reviewed: On 12/3/23 at 12:58 PM, resident 5 was seen by the facility Nurse Practitioner (NP). The NP note revealed, Nurse would like me to see patient today due to: .wound to labia, neck back and tailbone pain .currently taking Oxycodone 15 mg twice a day plus 4 hours when necessary .blood pressure 104/49 mmHg (millimeters of mercury) .All systems reviewed with no new concerns other than above .Generalized pain continue with Oxycodone 15 g twice a day plus every 4 hours when necessary .Review of DEA (Drug Enforcement Administration) site online: Hx (history) of drug overdose. Goal is no increases in narcotic pain medication as able. Pain management goal: Control pain level of independent physical function and quality of life. Monitoring for aberrant behavior and diagnosis that may increase pain; depression, anxiety and insomnia, and for severe risk factors: respiratory and cardiac rate changes. Nursing following levels each shift, may hold if lethargic. On 12/4/23 at 4:46 PM, a nursing progress note revealed, New order received from NP due to patient having low BP (blood pressure): If BP lower than 90/50 hold Oxycodone and elevate legs. Push fluids. Recheck BP manually to give Oxycodone. Resident aware. Medical team aware. On 12/9/23, no progress note was found regarding resident 5 having a low blood pressure, holding the Oxycodone due to low blood pressure, or re-checking the blood pressure prior to administration to the resident. On 1/11/24 at 1:51 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not trust the automatic blood pressure machines. RN 1 stated she checked the resident's blood pressure prior to administration. RN 1 stated if one of the blood pressure parameter was outside of orders but the other that was within orders she would contact the provider before giving Oxycodone. On 1/11/24 at 2:14 PM, an interview was conducted with the Director of Nursing (DON) who stated if the medication order stated Hold if blood pressure if less than 90/50, the medication should not be given.

Based on interview and record review, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 of 26 sampled residents, a resident who was prescribed an antibiotic for a urinary tract infection during an emergency room visit was provided the full course of the antibiotic without obtaining the results of the culture and sensitivity, which revealed the resident had MRSA and VRE infections. The resident was not placed on contact precautions and started on the effective antibiotic until 1/2/24. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess if right foot, acute congestive heart failure, acute embolism and thrombosis of upper extremity, aftercare following surgery on the skin and subcutaneous tissue, hypokalemia, chronic kidney disease, and morbid obesity. On 1/8/23 at 8:20 AM, an observation was mad of the door of resident 38's room. A sign on the door indicated that one of the residents in that room was on contact precautions. A nurse was observed exiting the room and an interview was conducted. Registered Nurse (RN) 3 stated resident 38 was on contact precautions due to having MRSA (methicillin-resistant Staphylococcus aureus) in his urine. Resident 38's medical records were reviewed. Physician orders included: a. Cefdinir oral capsule 300 mg (milligrams), Started on 12/21/23 and completed on 12/27/23. b. Macrobid 100 mg, Started 1/2/23 and discontinued on 1/3/23. c. Macrobid 100 mg, Started 1/3/23 and discontinued on 1/6/23. d. Macrobid 100 mg, Started 1/6/23 and discontinued on 1/9/23. e. Alert charting for UTI (urinary tract infection). Every shift until 12/30/23. Started 12/26/23 and completed on 12/30/23. f. Alert charting for UTI. Every shift for 8 days. Started 1/2/24 until 1/10/23. g. Contact isolation for a DX (diagnosis) of UTI/MRSA and VRE. Started 1/2/24 and completed on 1/7/24. On 12/21/23 at 4:05 AM, a nursing progress note stated, Note Text: Resident called me and said he was in excruciating back pain. Given Tramadol. Resident reports he has kidney stones. Asked him to give the Tramadol some time to work, but he states it's not strong enough. Resident said he feels like there issomething wrong and he wants to go to the hospital to be evaluated. Non-emergent transport called and resident taken to [hospital name removed]. Message sent to provider. On 12/21/23 at 9:29 AM, a nursing progress note stated, Resident returned from hospital via EMS (Emergency Medical Services). Resident is doing well. Pain is controlled at present .Resident does appear to have a UTl-cultures were sent. Resident should drink plenty of water. Antibiotics were started this evening. Resident is encouraged to ambulate more. Lortab, Tizanidine, and Cefdinir started. On 1/2/24 at 1:38 PM, a nursing progress note revealed, Urine results received from hospital. Resident's urine positive for MRSA an VRE. Hospital recommended resident be started on Macrobid 100 mg PO bid x 5 days. Provider notified and agreed to order. Resident notified of results, abx (antibiotic) order, and being placedon contact precautions. Resident is his own responsible party and stated he would notify his own family of results. First dose of Macrobid given. Resident placed on contact precautions. On 1/2/24 at 1:49 PM, an Interact Change of Condition evaluation revealed UTI results as the situation for the change in condition. The document included that medications were changed to Macrobid 100 mg during the past week. Functional status and mental status were not observed. Genitourinary evaluation included painful urination. Genitourinary symptoms listed were, slight burning with urination. Pain was evaluated and listed at 4/10, and was located in resident's back and described as persistent and not responding to exhisting or progressive orders with no new abnormal neurological signs. Laboratory tests included a urine culture with greater than 100,000 colony count with a urinary pathogen and symptoms. The pathogens were listed as MRSA and VRE (Vancomycin resistant enterococci). The date of the urine culture was 12/22/23 and the document states that urinary symptoms have stayed the same since that date. Finally, the document states that urinating made the symptoms worse, and drinking more water made the symptoms better. On 1/10/23 at 2:48 PM, an interview was conducted with RN 2 who stated the laboratory would fax or call over the results if they were significant. RN 2 stated the laboratory usually called. RN 2 stated if the lab did not call with results the nurse should call them. RN 2 stated if the results had not come back and was leaving the shift, the information would be given to the on-coming nurse to obtain the results. RN 2 stated if a resident came back from the hospital with new orders or a prescription, the nurse was responsible to let the provider know. RN 2 stated if the hospital did the urinalysis, they would also initiate the culture and sensitivity. RN 2 stated when the culture result came back, the hospital would call the facility with the results. RN 2 stated the reason it was important to follow-up on urine culture results was for antibiotic stewardship. RN 2 stated, you can just guess, but once the results are in then you can put the right antibiotic in place to avoid additional problems. On 1/11/24 at 11:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the results of the culture and sensitivity were not loaded into the resident's medical record because the staff member was behind. The DON stated the expected time to receive the results of a urine culture was unknown and was dependent on when the test was obtained and who saw the resident. The DON stated that sometimes it took 72 hours to get a result. The DON stated that usually the facility was the entity that sent out the culture, however, resident 38 was seen in the ER and the urologist that saw him ordered the culture and sensitivity. The DON stated the nurse was responsible to obtain a culture result if it had not been reported. The DON also stated that the incident occurred during the holidays, which may have been a factor in the late reporting. On 1/11/24 at 11:15 AM, an interview was conducted with the Corporate Resource Nurse (CRN) who stated if a resident went to the ER, the ER should request the lab results.

Based on observation, interview and record review the facility did not assure full visual privacy for 2 of 16 sample residents. Specifically, a resident did not have a curtain that extended around his bed to provide total visual privacy. Resident identifiers: 2 and 23. Findings include: 1. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included heart failure, malnutrition, stroke, depression, [CONDITION(S)], dysphagia, anxiety disorder, [CONDITION(S)], [CONDITION(S)], and acquired amputation of the lower right leg. On 3/14/22 at 10:33 AM, resident 23 was observed in her room and was interviewed. Resident 23 stated that her curtain was not long enough to provide full privacy. Resident 23 stated that if the curtain was pulled between the beds, so the residents could not directly see each other, there was a mirror that was located on the west wall that didn't allow for resident 23 to have privacy. Resident 23 stated that resident 2, her roommate, had frequent guests, and resident 23 could not have privacy. On 3/14/22 at 10:33 AM, the curtain in resident 23's room was observed to be too short to provide full visual privacy for resident 23. On 3/15/22 at 2:24 PM, the curtain in resident 23's room was observed to be too short to be pulled around resident 23's bed. On 3/16/22 at 7:46 AM, the curtain in resident 23's room was observed to be too short and to be pulled around resident 23's bed. 2. Resident 2 was first admitted to the facility on [DATE] and had subsequent readmissions with the most recent being 11/12/21, with diagnoses that included [CONDITION(S)], respiratory failure, renal failure, depression, and falls. On 3/14/22 at 10:33 AM, resident 2 was observed in her room, laying in bed. Resident 2 was observed to not have a privacy curtain. On 3/15/22 at 2:24 PM, resident 2's room was observed and resident 2 did not have a privacy curtain. On 3/16/22 at 7:46 AM, resident 2's room was observed and resident 2 did not have a privacy curtain. On 3/16/22 at 7:50 AM, the Maintenance Director (MD) was interviewed. The MD stated that he was responsible to install curtain rails and repair damaged curtain rails, but the laundry personnel were responsible to clean and hang privacy curtains. The MD stated that curtains were taken down and cleaned when there was a room change. The MD stated that he had never taken a curtain down. On 3/16/22 at 11:35 AM, the housekeeping supervisor (HS) was interviewed. The HS stated that curtains were taken down when staff needed to perform a deep clean or after a resident moved from the room. The HS stated that resident 2 and 23's room had not been deep cleaned in the past few months. The HS stated that there were adequate stores of curtains for all residents to have privacy, and the facility had a closet full. On 3/16/22 at 11:40 AM, the HS toured resident 23's room and stated that resident 23 could be provided a longer curtain. Resident 23 stated at that time to the HS that she would like a longer curtain to have privacy.

Based on observation and interview, it was determined the facility failed to properly prevent or contain COVID-19. Specifically, facility staff were not wearing personal protective equipment (PPE) appropriately. Additionally, a staff member failed to follow protocols to prevent the spread of COVID-19 by exiting a COVID-19 unit through the entrance barrier without doffing the PPE behind the protective barrier. Findings include: On 11/16/21 a Focused Infection Control Survey (FICS) was conducted at the facility during a COVID-19 outbreak. The facility, in coordination with the Utah Health Associated Infection (HAI) team, had constructed a COVID-19 unit in the hallway nearest the entrance to house COVID-19 positive residents during the outbreak. Two barriers were constructed where staff who needed to enter the COVID-19 unit could don the appropriate personal protective equipment (PPE) before entering the unit. Staff who entered the COVID-19 unit were instructed to exit the unit through a side entrance after doffing PPE before re-entering the facility where non-COVID-19 positive residents were residing. On 11/16/21 at 9:55 AM, an observation was made of the facility Activities Assistant (AA) exiting the COVID-19 unit through the entrance barriers with a gown on. An interview was conducted. The AA stated she passed out trivia and coloring pages to residents on the COVID-19 unit daily to provide them with an activity. The AA also stated she would be conducting a televised BINGO game later in the day. The AA stated when she entered the COVID-19 unit she washed her hands before going through the barrier. The AA stated she donned a gown and gloves in addition to the eye protection and 2 masks (N-95 covered by a surgical mask) before entering the unit. The AA stated, while on the COVID-19 unit, she stepped inside the resident's room to have a short conversation and provided each resident with the daily activity or other items they may have requested in a paper bag. The AA stated before she exited the COVID-19 unit, she removed her gloves and put them in the trash receptacle inside the barrier. The AA stated, regarding her gown, that she brought her gown down the hallway to the laundry room so it could be laundered. The AA then stated she was aware of the basket inside the barrier where gowns were to be placed after doffing and before exiting the COVID-19 unit. On 11/16/21 at 11:30 AM, an observation was made of the facility maintenance staff (MS) entering a resident room (23). The MS was observed to sanitize his hands before entering the room. The MS was also observed to be wearing a face mask. The MS was observed to be wearing his eye protection on his head and not over his eyes. The MS proceeded to work in the resident's room on a needed repair. On 11/16/21 at 12:07 PM, an observation was made of a hospice nurse (HN) exiting a resident room (18) after providing cares to one of the residents. The HN was observed to be wearing her eye protection resting on top of her head and not over her eyes. As she exited the room, she was observed to lower her eye protection to place it appropriately over her eyes. An interview was conducted. The HN stated hospice staff were able to enter the facility to provide cares during the COVID-19 outbreak, and starting this week hospice certified nursing assistants (CNA's) would be able to come and provide cares also. The HN stated she worked for [an agency] hospice and visited the resident weekly. On 11/16/21 at 1:10 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated the expectation for staff entering the COVID-19 unit was that they enter the first barrier, don a gown and gloves in addition to their eye protection and masks, before entering the second barrier. The ADM stated the staff would then provide cares. The ADM stated before exiting the COVID-19 unit through a side entrance, the staff should doff the gown and gloves and sanitize their hands before re-entering the non-COVID side of the building.

Based on interview and record review the facility did not conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals such as the positivity rate of COVID-19 in a county and based on the identification of any individual diagnosed with COVID-19 in the facility. Specifically, unvaccinated staff were not tested twice a week when the county transmission rate was Red and during their outbreak period. This occurred for 3 out of 3 sampled unvaccinated staff members. Findings include: Center for Medicare and Medicaid Services (CMS) Memo QSO (Quality Safety & Oversight)-20-38-NH, revised on 4/27/21, reads, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested . Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. [Community COVID-19 activity is High when the county positivity rate in the past week was >10% and minimum testing frequency of unvaccinated staff is twice a week.] For outbreak testing, all staff and residents should be tested , regardless of vaccination status, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The [NAME] County transmission rates used to determine staff testing frequency were as follows: · [DATE] Week 1 (10/3/21 to 10/9/21) Prior week's transmission rate: 12.8% Red transmission level required twice a week testing for staff. · [DATE] Week 2 (10/10/21 to 10/16/21) Prior week's transmission rate: 12.5% Red transmission level required twice a week testing for staff. · [DATE] Week 3 (10/17/21 to 10/23/21) Prior week's transmission rate: 13.6% Red transmission level required twice a week testing for staff. · [DATE] Week 4 (10/24/21 to 10/30/21) Prior week's transmission rate: 14.6% Red transmission level required twice a week testing for staff. · [DATE] Week 1 (10/31/21 to 11/6/21) Prior week's transmission rate: 15.7% Red transmission level required twice a week testing for staff. · [DATE] Week 2 (11/7/21 to 11/13/21) Prior week's transmission rate: 15.9% Red transmission level required twice a week testing for staff. · (Note: The facility's current COVID-19 outbreak started on 10/26/21, which also required twice a week testing for staff.) On 11/16/21 at 1:07 PM, the three unvaccinated staff members were selected for COVID-19 testing review. The facility's COVID-19 staff testing logs were reviewed with the administrator. 1. Certified Nursing Assistant (CNA) 2 met the twice a week testing requirements for October 2021, Weeks; 1, 2, & 4, and November 2021, Weeks; 1 & 2. CNA 2, who worked on the following days of October 2021, Week 3 (10/19/21, 10/21/21 & 10/23/21) was only tested on ce during that week on 10/19/21. 2. CNA 3 met the twice a week testing requirements for October 2021, Weeks; 1, 2, & 3, and November 2021, Weeks; 1 & 2. CNA 3, who worked on the following days of October 2021, Week 4 (10/24/21, 10/25/21, 10/27/21, 10/28/21 & 10/30/21) was only tested on ce during that week on 10/29/21. 3. CNA 4 met the twice a week testing requirements for October 2021, Weeks; 1 & 2, and November 2021, Weeks; 1 & 2. CNA 4, who worked on the following days of October 2021, Week 3 (10/17/21, 10/18/21, 10/19/21, 10/22/21, & 10/23/21) was only tested on ce during that week on 10/19/21. Additionally, CNA 4, who worked on the following days of October 2021, Week 4 (10/24/21, 10/25/21, 10/29/21, & 10/30/21) was not tested that week. On 11/16/21 at 1:07 PM, an interview was conducted with the administrator and corporate resource nurse (CRN) following review of the COVID-19 staff testing logs. The administrator and CRN acknowledged that the staff listed above should have been tested twice a week.

Based on interview and record review it was determined, for 3 of 21 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. Specifically, residents did not have monthly pharmacy reviews completed by the pharmacist. Resident identifiers: 4, 20, and 23. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 4 were reviewed. Resident 4 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) 2019. There was no form with recommendations for resident 4 for (MONTH) 2019. 2. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 20 were reviewed. Resident 20 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. 3. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The drug regimen review for resident 23 were reviewed. Resident 23 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. On 11/6/19 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident's were reviewed monthly by the pharmacist. The DON stated that she did not have the recommendation forms for resident 4, 20, and 23.

Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility staff did not immediately consult with the resident's physician when there was a significant change in the residents status. Specifically, a resident had elevated blood glucose levels with a physician's orders [REDACTED]. There was no documentation the the physician was notified. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. A physician's orders [REDACTED].= 2 (Units); 200-249 = 4; 250-299 = 6; 300-349= 8; 350-399 = 10; [PHONE NUMBER]=12 notify MD (Medical Doctor) if > (greater than) 400, subcutaneously before meals and at bedtime for [MEDICAL CONDITION]. Resident 20's Medication Administration Record (MAR) for (MONTH) 2019 revealed the following blood glucose (BG) levels on 9/27/19. A BG of 468 at 11:30 AM, a BG of 429 at 3:30 PM, and a BG of 434 at 8:00 PM. There was no documentation that the physician was notified. Resident 20's MAR for (MONTH) 2019 revealed on 10/2/19 at 3:30 PM, a BG of 405. There was no documentation that the physician was notified. A physician's orders [REDACTED].= 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 9; 350 - 399 = 11; 400 - 9999 = 13 notify MD if >400, subcutaneously four times a day for [MEDICAL CONDITION]. Resident 20's MAR for (MONTH) 2019 revealed the following BG levels. On 10/3/19 a BG of 442, on 10/4/19 a BG of 459, on 10/5/19 a BG of 420, on 10/8/19 a BG of 407, on 10/12/19 a BG of 425, and on 10/15/19 a BG of 415. There was no documentation that the physician was notified. On 11/5/19 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident blood glucose was over 400, the nurse documented the blood glucose, administered the insulin according to physician orders, and notified the physician. The DON stated there was a box for the nurses to check documenting that the physician was notified. The DON reviewed the MAR and there were no areas to document that the physician was contacted. On 11/5/19 at 3:33 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that there was no documentation that the physician had been notified when the blood glucose was greater than 400.

Based on observation, interview and record review, it was determined that for 1 of 25 sample residents, the facility did not ensure that each resident was safe from accident hazards. Specifically, a resident sustained [REDACTED]. The findings were cited at a harm level due to the resident not having adequate supervision to prevent falls. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/22/17 at approximately 9:10 AM, an observation was made of resident 35 laying in bed. The bed was not in the low position. Certified Nurse Assistant (CNA) 1 who was in the room confirmed that bed was not in lowest position. CNA 1 lowered the resident's bed approximately 12 - 18 inches to the lowest possible position. CNA 1 stated that staff will lower resident's bed but resident had access to bed control and would often return the bed to a normal height. Resident 35's medical record was reviewed on 6/22/17. Review of the admission MDS (Minimum Data Set) Assessment, dated 2/13/17, revealed that the facility staff assessed resident 35 as requiring limited assistance with a one person physical assist for transfers, ambulating, toileting, and bed mobility. The facility staff also identified that resident 35 had sustained falls in the last 2-6 months prior to admission. A Care Area Assessment (CAA) triggered for falls. The facility staff documented that the care area would be addressed in a care plan. Review of resident 35's care plan revealed an Activities of Daily Living (ADL) Self Care Performance Deficit care plan that was initiated on 2/7/17. The goal developed was Will safely perform Bed mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) (sic) with modified independence) through the review date. The interventions developed to achieve the goal included: Occupational (OT), Physical (PT), Speech-Language Therapy (ST) evaluation and treatment to establish functional maintenance program per physician orders, Requires extensive assist x 2 (two person assistance) for adls, .Encourage to use bell to call for assistance. 1. On 2/5/17 at 3:45 PM, an incident report documented, CNA found resident sitting in a corner of her room, crying stating that she slipped and hit her head and shoulder on her closet door. unsure of what she was doing. On 2/5/17 an actual fall care plan was developed. The goal developed was Will resume usual activities without further incident through the review date. The intervention developed was to replace the quad can with a walker. 2. On 2/21/17 at 9:00 AM, an incident report documented, Pt (patient) was getting up from chair at the dinning (sic) table. Pt's leg hit the sit (sic) of the chair, hitting the chair out from under pt and causing pt to lose her balance. Pt fell to the right side. S/S (signs and symptoms) of increased pain to right shoulder noted at time of fall. Skin remains intact. Pt states right shoulder does hurt more after the fall. Staff there with pt at the time of fall. Additionally, the facility staff documented, Her pants were too tight and she could not bend and stand up correctly. (Note: Resident 35 required limited assistance with a one person physical assist with dressing.) The investigation into the incident was completed. The facility staff documented, She was walking with clothes on that impaired balance and fell . The interventions that were in place prior to the fall included: Call light within reach, frequently used item within reach, clear pathways, ensure non slip footwear, use of walker. (Note: The actual fall and ADL care plan did not include interventions for frequently used items within reach, clear pathways or ensure non slip footwear.) The new intervention documented on the incident report was Family to remove clothes and replace with clothes that is appropriate. The actual falls care plan was updated to include the new intervention of proper fitting clothes and provide pants that are not tight and inhibit function. 3. On 2/23/17 at 3:02 PM, an incident report documented, Floor (sic) by PT and CNA face down on the floor next to her bed, yelling and crying. Noted to be bleeding from her nose. Stated that she was trying to get up, rolled out of bed. The investigation into the incident was completed. The facility staff documented, She was attempting to self transfer and toilet self when she lost balance and fell from bed. The new intervention to be implemented was medications review/labs (laboratory). On 2/23/17 at 3:11 PM, the facility Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN) Supervisor documented in a progress note, Found by PT and CNA after hearing a loud bang, found resident face down on the floor crying and screaming, noted that she was bleeding from both nares are (sic) swollen and tender with some discoloration. Has full ROM (range of motion) of all extremities, neuro (neurological) checks WNL (within normal limits) also VS (vital signs). Ice applied to nose scant bloody drainage, in bed with HOB (head of bed) up. Stated that she was trying to get up rolled out of bed falling onto the floor. Bed was in low position, call bell was clipped to her blankets with in easy reach. Daughter called message left to call facility. MD (Medical Director) and ADON (Assistant Director of Nursing) aware. On 2/23/17 at 6:00 PM, the facility LVN/LPN Supervisor documented in a progress note, NP (Nurse Practitioner) (name redacted) went into eval (evaluate) residents (sic) face/nose after fall, found her to be unresponsive this nurse also no reaction to sternal rubs, both pupils sluggish, drooling on right side, after approx. (approximately) 10 minutes became more alert, cognitively slow in response, after 30 minutes much brighter. NP requests eval (evaluation) at ER (emergency room ), daughter aware to meet her at the ER at (name of local hospital) EMS (Emergency Medical Services) called transported to (name of local hospital), report called to ER. Review of the hospital records indicated that resident 35 had a seizure with a low phenobarbital and valproic acid levels. The actual falls care plan was updated to include the new intervention of medication/labs. 4. On 2/28/17 at 3:45 PM, an incident report documented, Pt. found on floor of room, sitting in front of wc (wheelchair) facing the window. Pt had been in the DR (dining room) and pt took self in wc from the DR to pt's room. Brief wet with urine at time of fall. Pt reports pain to shoulder and lower back. No new skin concerns noted at time of fall. The investigation into the incident was completed. The facility staff documented, She attempted to self transfer and lost her balance. The new intervention to be implemented was to review the wheelchair for safety. The actual falls care plan was updated to include the new intervention of eval (evaluate) w/c (wheelchair) for safety. 5. On 3/15/17 at 8:15 AM, an incident report documented, CNA found resident on floor, calling out. This nurse found resident laying on left side on the floor leaning against the door jam. States that she did not hit her head then recounted this stating that she did. stated (sic) that she got up to go to the bathroom without help. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. She attempted to take herself to the bathroom and lost her balance and fell . The new intervention to be implemented was medication review and lab ordered. The actual falls care plan was updated to include the new intervention of seizure med (medication) review/labs re-education. 6. On 3/20/17 at 1:00 PM, an incident report documented, Pt found on floor laying face down along side the (sic) bed. Pt snoring at the time pt was found. Easily awaken. No noted injury. Call light within reach of pt, not activated. The investigation into the incident was completed. The facility staff documented, Pt is alert with confusions (sic) she is able to make her need known. She despite repeated education about call light use and waiting for assistance she continues to not use call light or ask for assistance. Pt was found laying on the floor with pillows under head, awoke easily and voiced no new complaints. The new intervention to be implemented was Encourage pt to have bed in lower position. 7. On 4/7/17 at 10:49 PM, an incident report documented, Found PT (patient) sitting on floor. Assessed cognitive function and assessed body. No abnormal findings. She was sat into bed. Neuro checks per facility protocol. MD notified. PT (patient) states she was trying to get into bed and she slid to the floor. The investigation into the incident was completed. The facility staff documented, Pt was found sitting on the floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c. The new intervention to be implement was Pt will be moved to room closer to nurse station as well as to bed which will make pt more visible to staff. On 4/7/17 at 10:52 AM, License Practical Nurse (LPN) 1 documented in a progress note, PT was found in her room. She stated that she had slid down her bed to the floor while trying to get into bed. Full assessment conducted yielding no notable concerns. PT placed into bed. Neuro checks per facility protocol. MD notified. On 4/8/17 at 10:23 PM, LPN 2 documented in a progress note, Patient returned from ED (emergency department). Patient has soft cast splint in place. Splint is to be kept on until follow up ortho (orthopedic) appointment in 1-2 days. Patient is to use w/c or crutches for mobility. On 4/10/17 at 11:18 AM, the ADON (Assistant Director of Nursing) documented in a progress note, IDT (Interdisciplinary Team) review of fall from 4/7/2017. At time of falls Had (sic) no skid socks on, no shoes, denied pain at time of fall, post fall pain 3/10 call light not activated. intervention to help prevent falls was to move closer to rear nursing station in a bed and re educated (sic) to call lights, items in reach and frequently used items, bed in lower position. Pt started to have swelling noted to left ankle and pain, x-ray was obtained and noted to have fx (fracture) to left ankle. family (sic) was notified upon x ray results She was sent to ER (emergency room ) for eval and treatment Review of hospital emergency room records, dated 4/8/17 at 7:01 PM, documented that upon x-ray of left ankle resident 35 sustained a distal fibular fracture with adjacent soft tissue swelling. A review of resident 35's ADL charting dated 4/1/17 through 4/16/2017 revealed that staff was not providing a two person transfer assistance during this time frame as documented in resident's care plan. Resident 35's actual falls care plan was not updated to include additional interventions. On 6/21/17 at approximately 1:10 PM, an interview was conducted with LPN 1. LPN 1 stated that on 4/7/17 he observed resident 35 sitting on the floor of her room with her back to the bed and legs extended outward. LPN 1 stated that he assessed the resident for pain, neurological status and muscular problems. LPN 1 stated that resident began to cry and when questioned as to why she was crying, resident stated she that she was scared because she had fallen. LPN 1 stated that the resident continued to deny pain. On 6/21/17 at approximately 1:40 PM, CNA 1 was interviewed. CNA 1 stated that resident 35 was provided with a low bed, call light in reach, bedside table and frequently used items in reach. CNA 1 stated that fall happened after breakfast and that resident's demeanor after the fall was the same as before the fall. CNA 1 stated resident did complain of pain in her leg and that the pain was reported to the nurse. (Note: This was resident 35's seventh fall in two months. The facility staff did not increase resident 35's supervision to prevent accidents from occurring.) 8. On 5/5/17 at 6:15 PM, the ADON documented in a progress note, resident has an assisted fall while being transferred from w/c to bed, was on bed and slide (sic) off, bed in lower position and lost her footing. No injury noted , (sic) no bruising, daughter called and left message fall (sic) at 6:12 pm, non slide socks on, walker in front of resident. Did not hit head per c.n.a On 5/5/17 at 8:46 PM, the ADON documented in a progress note, Resident had a fall while being transferred into bed was sitting on bed and slipped off, staff assisted , (sic) did not hit her head, walker was in front of her and c.n.a. turned to push w/c. Daughter called message left. No injury. Did not hit head. Will have two people assist when resident is sleepy. (Note: Resident 35's initial ADL's care plan indicated that two people were to transfer resident 35.) The actual falls care plan was updated to include lips (unknown) assessment-requires 2 person assist r/t (related to) cast/behaviors. (Note: The initial ADL's care plan indicated that resident 35 was to have a two person assistance with transfers.) 9. On 5/9/17 at 8:20 PM, a licensed nurse documented in a progress note, At about 2020 (8:20 PM) the nurse heard patient yelling for help to find patient on the ground with back against the bed. Bed was at it (sic) lowest position. Patient stated that she was trying to get herself in bed. Patient stated she took of (sic) her shoes and lowered the bed to the ground and tried to get in. No injuries were noted. Patient states her knee hurt but was able to do full ROM (range of motion) without pain. Call light was in reach. DON, family and MD were notified. On 5/10/17 at 5:21 PM, the DON documented in a progress note, IDT (interdisciplinary team) review of fall on 5/5/17 (and) 5/9/17.Pt was assisted to the floor as she began slipping and aide lowered her to floor voiced no new complaints at this time stated she tried to transfer self back to bed from w/c.New intervention: lips (unknown) assessments. The actual falls care plan was updated to include call light education and return demonstration. On 5/11/17 at 4:24 PM, the DON documented in a progress note, Spoke with (resident 35's daughter) that I think that this is behavior related as she had pants folded on bed, w/c cushion on bed and she was sitting on the floor but insisted she fell from bed. Pt reports that she activated call light but it was not in on. Call light was changed to bulb call light. Pt will not tell this nurse any further details of incident. CNA reported she attempted to go in to do vitals on pt and she refused to have vitals taken at that time. Daughter reports that she had conversation with pt earlier today, states she thinks mom may be in bad (sic) mood r/t her inability to visit r/t vital illness. States her mother is manipulative and act (sic) to get attention. 10. On 5/11/17 at 4:30 PM, the ADON documented in a progress note, Resident was on floor sitting next to bed, w/c was slightly away from bed with wheels locked and pressure reduction cushion set on bed, her pants and shirt were nicely folded. It appears that resident set herself on floor. No injuries noted she was crying and saying that she had her light on, call light not on , (sic) no socks on feet. unsure how resident could have slid out of bed with clothes folded on bed where she would have had to slide out. She stated that she slide (sic) out of bed. It appears to be possible behaviors , (sic) when speaking to daughter by DON she said she had not been up here due to being not there and that her mom had called her today and that she also though (sic) behaviors. No injuries , (sic) no pain more anxiety. On 5/12/17 at 7:02 PM, the DON documented in a progress note, IDT review of fall on 5/11/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: new bubble call light placed in room. The actual falls care plan was updated to include bubble call light. 11. On 5/21/17 at 9:17 PM, a licensed nurse documented in a progress note, At about 1845 (6:45 PM) Nurse was called to patients room to find patient on the ground in front of her dresser. Patient was on her but (sic) facing the door with non-slip socks on. Patient has a small scratch on the right side of her nose that may or may not be r/t fall. Patient has two bumps on the back of her head. No other injuries were noted. Patient neuro assessment was started and VS (vital signs) have remained normal. Family, DON and NP were noted. On 5/22/17 at 4:17 PM, the DON documented in a progress note, IDT review of fall on 5/21/17.Pt was found sitting on floor. She would not state what occurred however pt bed was found with clothes neatly folded laying on bed, w/c cushion sitting on end of bed, bed was in low position.New intervention: Eval (evaluate) w/c for anti-tips. The actual falls care plan was updated to include eval for anti-tips on w/c (pt r/t weigh (sic) tips w/c despite anti-tips bars as she will lean to side. Given reacher. 12. On 6/3/17 at 11:12 AM, the LVN/LPN Supervisor documented in a progress note, Heard resident calling out found resident sitting on floor at edge of bed with w/c tipped, stated that she was trying to look in her hamper 'scootted (sic) to close to the edge' assessed for injury none noted, assisted back into w/c . On 6/5/17 at 12:28 PM, the DON documented in a progress note, Pt was found sitting on floor. Yelling out for help.New intervention: Room moved . The actual falls care plan was updated to include room moved. 13. On 6/4/17 at 10:59 AM, the LVN/LPN Supervisor documented in a progress note, Early this am (morning) was yelling in her room that she wanted to get UP NOW!, explained that she needed to wait a few minutes as her CNA was finishing with someone else. 'I don't care tell her to get her butt in HERE NOW! again reassured that she would be in, several minutes while this nurse was in the room the CNA came and got her up, she then attempted to get something from the vending machine, was mad that she could not. She then went down into the dining room and started crying because another resident in her 'Spot' and that no (sic) cares that she had to wait this am (morning). after breakfast went into her room, walked into bathroom without assist then fell on to right side with her face turned to the floor, noted to have a discoloration on forehead and small reddened area on her right side, had full ROM WNL assisted up into w/c X 4 (four) persons as she will NOT hold her own wt (weight). VS and Neuro checks good, assisted into bed with call bell and bed controls in reach. Shortly after CNA found resident laying sideways in her bed attempting to get up again, stated that she wanted to get up, asked why she did not call 'I don't need help' assisted into w/c. at nurses desk now. Daughter called about fall no answer message left to call facility, DON and PA (Physician's Assistant) aware of fall. On 6/5/17 at 12:34 PM, the DON documented in a progress note, IDT review of fall on 6/4/17.Pt was found laying on floor. Yelling out for help. Earlier in the day she told 'CNA' let (sic) see what happens when I fall as a response to aide helping get roommate dressed before her.New intervention: Dipstick ua (urinalysis) . The actual falls care plan was updated to include ua dipstick. On 6/5/17 at 10:49 AM, the DON documented in a progress note, Ua negative. On 6/6/17 at 4:17 PM, the ADON documented in a progress note, .has had some increased behavior and will tell staff that she is going to fall if she is not treated like their mother. She has some confusion will yell out at times and just scream, not r/t pain. She rated her pain 5/10 sometimes, has some SOB (shortness of breath) with activity, laying flat and rest ,is (sic) on oxygen when in bed. she did have a fall with fx (fracture). She remains a fall risk to (sic) despite intervention. Is ext (extensive) two person to stand transfers and toilet, ext for all adl functional cares, she could assist with dressing and washing face but needed assist and cues to assist.She could recall two word with cue sock, bed , (sic) blue knew yr (year) new month not day.She has confusion and other times she can answer questions from the past , (sic) knows staff names at times.has weakness in bialt (sic) (bilateral) legs and UE (upper extremities. 14. On 6/8/17 at 9:16 PM, a licensed nurse documented in a progress note, I was called into the patients bathroom by another nurse. Pt was lying on her R (right) side on the floor of the bathroom. there were no visible injuries, and no new c/o (complaints of) pain. at the time. pt's call light was on, aid/staff members were attempting to answer the patients call light, when the patient became anxious and tried to stand on her own. pt has been educated numerous times by staff and family to wait for help with cares. pt verbalizes understanding but continues to be noncompliant. pt was assisted back into her w/c, assessed further for any injuries, pt was cleaned up, and helped into bed for the evening. (Note: This was resident 35's fourteenth fall since her date of admission.) On 6/9/17 at 6:50 PM, the DON documented in a progress note, IDT review of fall on 6/8/17.Pt was found sitting on floor in bathroom. Yelling out for help. She had attempted to assist herself off of toilet.New intervention: Toilet Riser don't leave unattended in bathroom . The actual falls care plan was updated to include dont (sic) leave unattended in bathroom and toilet riser. On 6/22/17 at approximately 9:00 AM, an interview with the DON was conducted. The DON stated that the facility provided staffing according to the resident acuity and that acuity was based on resident behaviors and amount of assistance need for ADL's. The DON further stated that it was difficult to determine how much assistance resident 35 would need on a daily basis because her behavior and needs differed from day to day. The DON did acknowledge that the facility was not capable of providing resident 35 with 1 on 1 supervision. The DON stated that the facility had attempted several other interventions such as moving resident 35 closer to the nurses station but resident 35 and resident 35's daughter complained which led facility to moving resident 35 back to her original room. The DON stated that one of the earliest interventions put in place by the facility was a quick response time to the call light and resident reassurance that help would be available quickly but that resident 35 would still attempt unassisted self transfers. The DON also stated that the facility attempted to provide a wedge cushion and anti-tip bars on wheelchair but resident would often remove the cushion and anti-tip bars did not prevent her from sliding forward in her wheelchair.

Based on interview and record review it was determined, for 1 of 30 sample residents, that the facility did not honor choices about aspects of his or her life that were significant to the resident. Specifically, a resident was restricted from leaving the facility for having a history of [MEDICATION NAME] use. Resident identifier: 100. Findings include: Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 100's medical record was completed on 3/17/16. On 3/12/16 at 11:51 PM, facility staff completed a Daily Skilled Documentation form which revealed resident 100 was Alert and Oriented X (times) 4 (person, place, time and situation). On 3/13/16 at 11:14 PM, facility staff completed a Daily Skilled Documentation form which revealed resident 100 was Alert and Oriented X 4. A Physician order [REDACTED]. Family visits in common area inside facility for supervision per MD (Medical Doctor). On 3/12/16 at 8:00 PM, a facility nurse documented, pt (patient) returned back to facility, pt was LOA (Leave of Absence) with family and friends. pt has history of [MEDICATION NAME] abuse. DON (Director of Nursing) and MD notified of situation, new orders for UA (urinalysis) with toxicology screen. pt is no longer able to leave the facility, except with staff member. and family/friend visitations will be held in a common area inside the building per MD. On 3/14/16 at 2:53 PM, an interview was conducted with resident 100. Resident 100 stated she wanted to go the store to get hair spray and some other personal things, but was not sure of the rules. Resident 100 stated she had not been told she could not leave the facility. Resident 100 stated she was allowed to leave the facility on 3/12/15 with her sister to go to her house and check on her dog and make sure her bills would be paid while she was at the facility. On 3/15/16 at 10:29 AM, an observation was made of resident 100 sitting in the main lobby of the facility with her walker and her purse. Resident 100 stated she was waiting to go to the store but facility staff had not come to talk to her, Like they said they would. On 3/15/15 at 12:35 PM, a follow up interview was conducted with resident 100. Resident 100 stated the nurse told her she could not leave the facility without staff escorting her. Resident 100 stated, They are treating me like a child. Resident 100 stated she wanted to go the store to get supplies for her hair. Resident 100 stated she felt facility staff were taking away her Dignity. Resident 100 further stated she waited in the front lobby All morning to talk to the administrator but that he was busy with meetings. Resident 100 stated the administrator just left her room About 10 minutes ago and told her she had to ask her nurse for permission to leave the facility and when she asked her nurse she was told she had to have staff escort her. Resident 100 stated, I am so pissed off. Resident 100 was then observed to begin crying and blowing her nose with tissues. Resident 100 further stated, I am not a child. (Note: As this surveyor was walking out of resident 100's room the facility Director of Nursing (DON) walked in to her room.) On 3/15/16 at 12:51 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 100 had asked her if she could leave at approximately 12:30 PM, and RN 1 told resident 100 that she had to have a staff member go with her. RN 1 stated resident 100 then became upset and began asking why. RN 1 stated looking through resident 100's chart and what was passed on in report, it appeared resident 100 could not leave without staff due to a History of [MEDICATION NAME] use. RN 1 stated before she could tell resident 100 why she could not leave without staff resident 100 Became upset so RN 1 asked the resource nurse to tell resident 100 why. RN 1 stated she had wanted to review resident 100's chart to see if the [MEDICATION NAME] use was recent or an Old history. RN 1 stated if it was an old history she would have Advocated for resident 100 to be able to leave without staff. RN 1 stated she had not had time to review resident 100's chart so she was going off the physician's orders [REDACTED]. On 3/15/16 at 12:56 PM, during the interview with RN 1 resident 100 approached this surveyor and RN 1. Resident 100 stated she was sorry for being upset, and that the DON stated she could leave the facility without staff. Resident 100 further stated the DON was going to tell her yesterday that she could leave without staff but forgot. Resident 100 stated she was going to check herself out and go to the store. On 3/15/16 at 12:58 PM, a follow up interview was conducted with RN 1. RN 1 stated it was new information to her that resident 100 was allowed to leave the facility without staff. RN 1 stated she was going off what she was told in report and the physician order. On 3/15/16 at 1:06 PM, an interview was conducted with the facility DON. The DON stated resident 100 was Of course allowed to leave here and stated The nurse did not put the order in properly. The DON further stated the nurse on duty on 3/12/16 was concerned when resident 100 returned from a leave of absence with her sister because resident 100 was acting Suspicious. The DON stated the nurse on duty called her and told her He knew meth ([MEDICATION NAME]) (use) when he saw it and resident 100 and her sister looked like they had been on Meth. The DON stated she informed the nurse to call the doctor, and the doctor informed the nurse to obtain a urine toxicology. The DON stated the facility staff was concerned about the residents safety and that was why she was restricted. The DON stated she had no concerns about resident 100's safety today, and that resident 100 had not attempted to leave the facility after 3/12/16 until today, 3/15/16. The DON further stated all facility residents were not supposed to leave the facility unless they were with their responsible party or the resident was their own responsible party. On 3/15/16 at 2:09 PM, a follow up interview was conducted with the DON. The DON stated resident 100 was her own responsible party. On 3/17/16 the facility obtained and provided the results of resident 100's urine toxicology test from 3/12/16 which revealed [MEDICATION NAME], Barbiturates, Benzodiazepines, THC (Tetrahydrocannabinol)-50, Opiates, and Cocaine were NOT DETECTED.

Based on interview and record review it was determined for 1 of 30 sample residents that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was transferred with a hoyer lift using a sling which was too small which resulted in a hip fracture. Resident identifier: 56. Findings include: Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 56's medical record was completed on 3/17/16. On 9/10/15, facility staff completed an Admission Minimum Data Set (MDS) assessment for resident 56. Facility staff assessed that resident 56 required, Two (plus) person physical assist for bed mobility and transfers. Nursing Note entries for resident 56, between 10/31/15 and 11/2/15, included the following documentation: a: On 10/31/15 at 1:14 PM, a facility nurse documented, Resident has had increased pain throughout the day . b: On 11/1/15 at 4:54 AM, a facility nurse documented, Residents results of xray returned. Results read to (Name of facility Nurse Practitioner), NP. Sent to (Name of local acute care hospital) for possible fracture of right femor (sic). c: On 11/1/15 at 5:19 PM, a facility nurse documented, Resident returned from hospital at about 10 am, has be (sic) DX (diagnosed ) with right hip fracture . Has rested in bed through out shift, no increase of pain, Continues to rest in bed pain increased with movement, or transfers. WCTM (will continue to monitor). d: On 11/2/15 at 5:01 PM, a facility nurse documented a late entry for 10/31/15 at 12:00 PM which revealed the following information, While at the med (medication) cart, the CNAs (Certified Nursing Assistants) came out of residents room and informed me that the resident had slid in the sling during a transfer from her bed to her electric wheelchair. The CNAs said that she had bumped her head on the hoyar (sic) bar and had pain associated with it. Resident reported that she had a slight headache, but that she had a lot of pain in her right leg. She was not able to describe where in the right leg it hurt, just that she was in pain. I assessed her leg while she was in the chair. No swelling, heat, bruising, or redness noted. She had pain upon movement, but not palpation. Res VS (vital signs) WLN (sic). Administered PRN (as needed) pain medication. Pain medication alleviated the pain for some time. When it was available I medicated again for pain and helped to transfer her into bed. While in bed I reassessed her right leg. No swelling, redness, bruising, or warmth noted. Right leg elevated on pillow. After medicating the second time I told her that if the medication and rest in bed did not help we could get an x-ray of the leg. On 3/16/16 at 1:19 PM, an interview was conducted with CNA 1. CNA 1 stated she was one of the aides who assisted resident 56 to her wheelchair on 10/31/15. CNA 1 stated herself and another aide were transferring resident 56 when the resident became Really aggressive because She (resident 56) didn't like the sling we were using, she was trying to get out of it and She (residsent 56) didn't like the other aide. CNA 1 stated during the transfer resident 56 hit her Head and side on the pole of the hoyer lift. CNA 1 stated resident 56 Didn't feel safe with the sling she and the other aide used to transfer resident 56 because the sling was not big enough for resident 56. CNA 1 stated she and the other aide had to use the sling which did not fit resident 56 because it Was the only one we had at the time. CNA 1 stated the sling stopped mid shoulder bilaterally on resident 56 but was supposed to cover all of her shoulders. CNA 1 further stated A couple of days after resident 56 hit the hoyer lift with her head and side the facility purchased a bigger sling for resident 56. On 3/16/16 at 1:43 PM, a follow up interview was conducted with CNA 1. CNA 1 stated on 10/31/15 the transfer of resident 56 was going Fine until the lift was Up high and that is when resident 56 Started wanting to get out. CNA 1 stated resident 56 Absolutely didn't like the other aide with me that day. CNA 1 further stated resident 56 was Moving around a lot and Hit her side and her head on the pole of the hoyer lift. CNA 1 stated resident 56 Was trying to get out and was Swearing. CNA 1 stated resident 56 Absolutely hated the other aide who assisted during the transfer of resident 56 on 10/31/15. CNA 1 further stated resident 56 Would try and hit the other aide. CNA 1 stated she was working the controls on the lift while the other aide was attempting to guide resident 56 into her chair. CNA 1 stated when resident 56 began trying to get out of the hoyer sling the other aide Was trying to calm her down but because resident 56 Didn't like the other aide it did not calm resident 56 down. CNA 1 stated the other aide was More built and Stronger than her so that is why the other aide was supposed to physically guide resident 56 by using the handles on the sling. CNA 1 stated when resident 56 was moving she Physically hit her head and her side and complained of pain. CNA 1 further stated the other CNA was attempting to control resident 56 as she was moving but that Once she (resident 56) was up, no one is that tall to grab on to the sling. CNA 1 stated she went and got the nurse as soon as resident 56 was in her wheelchair and told the nurse what had happened. CNA 1 stated when resident 56 came to the facility there was only one size of hoyer sling for staff to use and that size didn't cover resident 56's shoulders. CNA 1 further stated the facility Bought a lot of different sized hoyer slings after the incident with resident 56. CNA 1 stated there were other CNAs working during the time she and another CNA transferred resident 56 on 10/31/15 but that she did not think to ask another aide to assist her because she and the other CNA were working the same section. CNA 1 agreed it would have been the Better thing to do to have asked another aide to assist her during resident 56's transfer. CNA 1 confirmed resident 56 hit her right hip area and her head. CNA 1 further stated resident 56 complained of pain down her whole right side. On 3/17/16 at 11:43 AM, an interview was conducted with the facility Administrator. The Administrator stated he was told several months ago the facility needed more hoyer slings, so he ordered them. The Administrator was unsure if the need for new hoyer slings correlated with resident 56's incident on 10/31/15. The Administrator stated he thought that because resident 56 had osteoporosis the actual pressure from the sling on resident 56's right hip joint was what caused her fracture. The Administrator stated he didn't think resident 56 could have hit her hip hard enough to cause a fracture.

Based on observation, interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 30 sample residents. Specifically, antibiotics were not available for administration as ordered, abnormal weights were not reported to the primary care physician, and a back brace was not obtained as ordered. The deficient practice for resident 30 was cited at a harm level. Resident identifiers: 30, 47, and 100. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30's medical record was reviewed on [DATE]. Review of the DISCHARGE SUMMARY FOR EXPIRED RESIDENTS revealed, Resident here for long term care due to MX (multiple) medical conditions. He admitted with a UTI (urinary tract infection) and pneumonia.[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphylococcus aureas) in urine cultured during stay but resident had significantly declined. a. admission orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. b. On [DATE], an order was received to administer [MEDICATION NAME] 1 gram intramuscularly at bedtime for three days related to a possible urinary tract infection. A review of the [DATE] MAR indicated [REDACTED]. c. On [DATE], an order was received to administer [MEDICATION NAME] 750 mg intravenously one time a day [MEDICAL CONDITION]. A review of the [DATE] MAR indicated [REDACTED]. On [DATE] a wound on resident 30's back was cultured. The culture and sensitivity returned with [MEDICAL CONDITION] infection on [DATE]. (Note: [MEDICAL CONDITION] infection was on resident 30's back and not in his urine as documented on the DISCHARGE SUMMARY FOR EXPIRED RESIDENTS.) Review of the licensed nurses progress notes revealed the following entries: a. [DATE] at 5:00 PM: .Alert, oriented X 4 (person, place, time and situation).Resident has labored breathing. Resident has shallow respirations. Resident has dyspnea/SOB (shortness of breath). b. [DATE] at 5:00 PM: .Alert, Oriented X 3 (person, place, and time). c. [DATE] at 3:13 PM: .Redness with open sites along panus [MEDICATION NAME] powder ordered, cx (culture) to L (left) lateral abdomen open sore collected. d. [DATE] at 6:40 PM: Obtain UA (urinalysis) with cx one time only for UTI for 1 day unable to obtain.-lab refused UA as they use a different cup and tube for urine, cups and tubes ordered lab to bring. e. [DATE] at 7:01 PM: .[MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth at bedtime for MAINTANCE (SIC)/PREVENITIVE (sic) FOR UTI NO MEDICATION AVAILABLE. f. [DATE] at 7: 35 PM: . [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth at bedtime for MAINTANCE (sic)/ PREVENITIVE (sic) FOR UTI Awaiting arrival from pharmacy. g. [DATE] at 8:08 PM: .[MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth at bedtime for MAINTANCE (sic) / PREVENITIVE (sic) FOR UTI no medication available. h. [DATE] at 7:34 PM: .[MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth at bedtime for MAINTANCE (sic) / PREVENITIVE (sic) FOR UTI No supply, pharmacy notified. i. [DATE] at 4:31 PM: .Residents wound c/s (culture and sensitivity) came back with [MEDICAL CONDITION]. Resident kidney functions show some concern, contacted pharmacist for dosing recommendation . pharmacist would like to start dose of 750 mg every 24 hours. Provider agrees with pharmacist recommendation. PICC (peripherally inserted central catheter) nurse called to come in to place PICC.[MEDICATION NAME] to be at 2000 (8:00 PM) R/T (related to) pharmacy draw times are in the evening for trough draws, Day nurse taking care of resident notified of plan of care. PICC nurse came in at appx (approximately) 1630 (4:30 PM) to place PICC, resident consented at this time. j. [DATE] at 6:59 PM: Late entry: .Resident placed on IV (intravenous) vancomyacin (sic) today to [MEDICAL CONDITION] in a wound, Picc nurse called to place PICC.Through out the afternoon the resident was becoming increasingly confused.Resident received scheduled medications with no issues. Resident did not consume any of his dinner. He did take his evening medications with no problems. Through out the remainder of the evening resident was experiencing hallucinations, on and off through out the evening. Vancomyacin (sic) did not come until 1200 am, at which time this nurse and another nurse reviewed the orders, at which time is (sic) appeared that the medication was to be administered at 8 am, and it was determined that the medication order would need to be clarified. Which was to be passed on to the day nurse. k. [DATE] at 8:51 PM: .[MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth at bedtime for MAINTANCE (sic) / PREVENITIVE (sic) FOR UTI Not available at this time. l. [DATE] at 1:10 PM: . RA (Resident Advocate) was notified by MD (Medical Doctor) that (resident 30) has had decline and recommending hospice or to be sent out.(Resident 30's brother) notified of current situation related to infection and [MEDICAL CONDITION]. Education provided on infection and offered to send to hospital for further treatment. Notified (resident 30's brother) of seriousness of situation . m. [DATE] at 9:41 PM: .(Resident 30) was placed on hospice today. He is actively dying. On [DATE] at approximately 10:00 AM, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 30 did not receive the [MEDICATION NAME], or [MEDICATION NAME] as ordered by the physician. 2. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 47's medical record was reviewed on [DATE]. On [DATE], resident 47 was seen by his Advanced Practice Registered Nurse (APRN). The APRN indicated that resident 47 had an x-ray on [DATE] for lumbar pain. The APRN documented that the x-ray came back showing anterolisthesis meauring (sic) 11 mm (millimeters) and L5-S1 [MEDICAL CONDITION] changes of the lower portion of the lumbar spine possibly due to [MEDICAL CONDITION] findings but very suggestive of pars interarticularis defects of L5 there is also [MEDICAL CONDITION] changes of bilateral sacroiliac joints . The APRN wrote an order for [REDACTED]. On [DATE], resident 47 was again seen by his APRN for pain. The APRN indicated that resident 47 had shoulder and back pain throughout [MEDICAL TREATMENT]. The APRN increased resident 47's pain medication. On [DATE], resident 47 was seen for a spine consult. Facility staff documented on a transfer form that resident 47 was having pain that was having a very negative impact on his mobility, appetite, activities of daily living, etc. The physician indicated on the transfer form that resident 47 had spondyloisthesis, and ordered a back brace for lumbar support. On [DATE] at 8:48 AM, an interview was conducted with resident 47, as he was laying in bed. Resident 47 stated that he was in pain all the time in his legs, feet, shoulder, and back. Resident 47's room was observed during this time, and no back brace was observed in his room. On [DATE], an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that resident 47 did have a back brace, but facility staff did not know where the back brace currently was. 3. Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 100's medical record was completed on [DATE]. A Physician order [REDACTED]. Weight entries for resident 100, between [DATE] and [DATE], included the following documentation: a. On [DATE], 212 pounds b. On [DATE], 211.8 pounds c. On [DATE], 237 pounds d. On [DATE] at 4:08 AM, 236.4 pounds e. On [DATE] at 2:24 PM, 238.6 pounds f. On [DATE], 239 pounds (Note: Per facility documentation resident 100 gained 25 pounds from admission to [DATE], and a total of 27 pounds from admission to [DATE].) On [DATE] at 11:56 AM, an interview was conducted with RN 2. RN 2 stated when a resident had an order to notify the physician of weight gain the order would specify how much weight gain would warrant physician notification, usually a three pound weight gain in one day. RN 2 then stated resident 100's order did not specify when to call the physician. RN 2 stated the order needed clarification.